21-22 JANUARY 2010, Rotterdam, The Netherlands
WEDNESDAY, 20 January 2010
Defense Rik Vos (Erasmus University Woudestein)
Single microbubble imaging
18.00 - 20.00
Registration - Welcome Drinks – Posters ..................................................................... Hilton Hotel
THURSDAY, 21 January 2010
08.00 - 09.00
09:00 - 09:10
Introduction and opening ........................................................................................... Folkert ten Cate
09.10 –10.40
Nicolas Rognin
GENERAL ULTRASOUND CONTRAST IMAGING . Chairpersons: Folkert ten Cate / Ton van der Steen
3D Contrast Enhanced Stress Echocardiography ...................................................................................................
Why do we need to visualize microvessels in an atherosclerotic plaque? A pathologist view ...................
Contrast enhanced ultrasound for intraductal application of contrast agent in obstructive diseases of the salivary
Lymphatic pathways visualization and sentinel node identification with harmonic imaging and second
generation echoenhancer ........................................................................................................................................
Parametric Imaging of Dynamic Vascular Patterns of Focal Liver Lesions in Contrast-Enhanced Ultrasound .......
10.40 – 11.10
11.10 – 12.40
Mark Monaghan
Mat Daemen
Pamela Zengel
Rodolfo Lanocita
Tom Porter
Stephen Meairs
Sibylle Pochon
Ine Lentacker
The Effects of Platelet versus Fibrin Targeted Microbubbles on the Success of Ultrasound and Microbubble
Mediated Thrombolysis……………………… ...........................................................................................................
Directing adipose derived stem cells to the area at risk in the heart after myocardial infarction using targeted
Microbubbles…………………………………………………… ...................................................................................
Advances in microbubble applications for treatment of brain disease …………………………………………………
Molecular imaging of angiogenesis with BR55: a VEGFR2-targeted ultrasound contrast agent…………………….
Tumor cell killing efficiency of doxorubicin-liposome loaded microbubbles after ultrasound exposure…………….
12.40 – 14.10
14.10 – 14.40
Coeur lecture ..............................................................................................Chairperson: David Cosgrove
Role of CEUS in Endovascular Aneurysm Repair (EVAR) procedures and during the follow-up ………………… . 19
14.40 – 16.10
Peter Burns
Liza Villanueva
Christophoros Mannaris
Pedro Sanches
Jeroen Sijl
TECHNOLOGY 1 ......................................................... Chairpersons: Thomas Albrecht / Mark Monaghan
Convertible Liquid Droplets for Ultrasound Contrast ............................................................................................... 20
Stem cell tracking using ultrasound ......................................................................................................................... 23
Experimental investigation of microbubble response to ultrasonic pulses used in therapeutic applications………. 24
SPECT/CT Imaging and Quantification of Focused Ultrasound Induced Extravasation………………………………. 28
The origin of “compression only” and enhanced subharmonic behaviour of phospholipid-coated ultrasound
contrast agent microbubbles……………. ................................................................................................................ 30
16.40 – 18.00
Hessel Wijkstra
Paul Sidhu
Ferdinand Frauscher
Maarten Kuenen
Peter Frinking
PROSTATE + RENAL APPLICATION ...................... Chairpersons: Hessel Wijkstra / Ferdinand Frauscher
Follow-up of Cryoablation in kidney cancer: CT versus CEUS ...............................................................................
Can Contrast Enhanced Ultrasound of the Scrotum be used as a problem solving tool .........................................
The future of prostate cancer diagnosis……………………………………………….. ...……………………………….
Ultrasound contrast agent diffusion imaging for localization of prostate cancer...................................... ………….
Real-Time Contrast-Enhanced Ultrasound Parametric Imaging in Prostate ...............……………………………….
18.30 – 22.30
SOCIAL EVENT (Incl. Dinner buffet) .............................................................................................................. 49
Lynda Juffermans
Dirk Clevert
21-22 JANUARY 2010, Rotterdam, The Netherlands
FRIDAY, 22 January 2010
07.30 - 08.00
07.30 - 09.00
A1) Anna Tokarczyk
......................................................Moderator: Folkert ten Cate
Development of a cannulated vessel model for simultaneous ultrasound exposure and microscope imaging ....... 50
A2) Francesco Bartolomucci Assessment of coronary flow reserve, myocardial perfusion and function in two cases of Takotsubo
cardiomyopathy. Insights into pathophysiological mechanisms .............................................................................. 51
A3) Ingeborg Herold
Blood volume and ejection fraction measurements using CEUS ............................................................................ 54
A4) Leo Deelman
Ultrasound and microbubble mediated gene therapy: effectiveness of siRNA versus plasmid DNA delivery......... 56
A5) Bart Geers
Virus loaded microbubbles as a tool for targeted gene delivery .............................................................................. 57
A6) Julien Piron
Enhancement of doxorubicin effect on cancer cell mortality with ultrasound and microbubbles ............................. 59
A7) Catalin Toma
Targeted delivery of cell-based therapy for vascular repair using acoustic radiation force ..................................... 61
A8) Esther Leung
Tracking of the Left Ventricular Borders in Contrast-Enhanced Ultrasound Images ............................................... 63
07.30 - 09.00
POSTER DISCUSSION B............................................................................... Moderator: Nico de Jong
B1) Jack Honeysett
Microbubbles for Acousto-Optic Imaging Signal Enhancement .............................................................................. 64
B2) David Thomas
Development of quantitative contrast ultrasound imaging using the ovine ovarian model ...................................... 65
B3) Helen Mulvana
Effect of Temperature on the Acoustic Characteristics and Stability of Ultrasound Contrast Agents...................... 66
B4) Francesco Conversano Optimal use of Silica Nanoparticles for Enhanced Ultrasound Imaging and Automatic Tissue Typing ................... 70
B5) Mairead Butler
The acoustic response of individual microbubbles in tubes .................................................................................... 74
B6) Brandon Helfield
Investigating the nonlinear response of individual lipid encapsulated microbubbles at high frequencies ............... 76
B7) Anthony Novell
Wideband Harmonic imaging of ultrasound contrast agent with a CMUT Probe .................................................... 78
B8) Telli Faez
Subharmonic spectroscopy of ultrasound contrast agents ...................................................................................... 80
21-22 JANUARY 2010, Rotterdam, The Netherlands
FRIDAY, 22 January 2010
09.00 - 10.40
David Maresca
Tom Shorrock
TECHNOLOGY 2 ................................................................................ Chairpersons: Peter Burns / Tom Porter
Ultra high speed fluorescence imaging of ultrasound triggered local drug release ………………………………… .
Parametric Ultrasound Contrast Imaging with a Micro-Ultrasound System: A Reproducibility Study in Mice .…….
An In Vivo Model for Real Time Visualization of Microbubble-Mediated Sonothrombolysis in the Microcirculation
Ultrasound and Microbubble enhanced cell permeability through generation of transient sub-micron
disruptions on the plasma membrane: Transmission electron microscopy studies…………………………......……
Acoustic sizing of an ultrasound contrast agent ..........................................................……………………………….
Towards an ultrasound contrast method for imaging extavascular molecular targets........ ………………………….
10.40 – 11.10
11.10 - 12.40
Natalya Rapoport
Raffi Bekeredjian
Christy Holland
Klazina Kooiman
Alexander Klibanov
DRUG DELIVERY ......................................................... Chairpersons: Ayache Bouakaz / Liza Villanueva
Phase-shift nanoemulsion/microbubble platform for ultrasound-mediated drug delivery ..... ……………………….
New developments in therapeutic applications of microbubbles: An update……….. ..……………………………….
Ultrasound-Mediated Drug Delivery using Echogenic Liposomes………………………………………………………
Drug uptake by endothelial cells through targeted microbubble sonoporation ........................................................
Tumor therapy by microbubbles and ultrasound: mechanism of tumor growth control……………………………….
12.40 – 14.00
Erik Gelderblom
Andrew Needles
John Pacella
Raffi Karshafian
Announcement of the winners of the Martin Blomley poster prize and the technical poster-prize.
14.00- 15.30
Steve Feinstein
Edward Leen
David Owen
Liselotte Kornmann
Joshua Rychak
VASCULAR IMAGING ................................................................... Chairpersons: Christy Holland / Otto Kamp
Review of vascular imaging with Contrast-enhanced ultrasound (CEUS) ………………………. ……………………
Plaque Imaging ………………………. ....................................................................................... …………………….
Late Phase Contrast Enhanced Ultrasound to Assess Inflammation within Carotid Atherosclerotic Plaque …… ..
In vivo targeting of mouse carotid artery endothelium using echogenic perfluorohexane loaded macrophages….
Imaging Angiogenesis with Cyclic Peptide Microbubbles............................................……………………………….
15.30 - 15.45
DISCUSSION AND CONCLUSIONS .........................................................Folker ten Cate / Nico de Jong
............................................................................................................................................................... 120
FIRST ANNOUNCEMENT 2011 ................................................................................................................................................ 121
3D Contrast Enhanced Stress Echocardiography
Dr Mark J Monaghan
Real-time three-dimensional stress echocardiography represents a major advance in the
evaluation of ischemic heart disease. It has been performed with exercise and dobutamine with
a high feasibility and good sensitivity and specificity for detection of angiographic coronary
artery disease and has been combined with contrast to increase the visualization of segments at
rest and during stress. Advantages of 3D for stress echocardiography include better
visualization of the left ventricular apex, which is frequently foreshortened on standard twodimensional apical images, very rapid acquisition of peak stress images before the heart rate
declines in recovery, and the possibility to image segments from multiple planes using a single
dataset. Disadvantages include a lower spatial resolution and lower frame rates for imaging.
Moreover, only recently has 3D technology permitted side-by-side display of rest and stress
Contrast specific imaging modalities which have been available in 2D imaging systems for
many years are now available on 3D systems. These modalities are extremely helpful in
patients with sub-optimal image quality and may be used in both LVO and Low MI modes for
MCE. Whilst the value of performing 3D LVO studies is pretty self evident, experience with
3D MCE is limited. It may be that this technology will be most useful during vasodilator stress
studies.The incremental value of contrast to resting and stress 3D studies will be discussed in
this presentation.
Why do we need to visualize microvessels in an
atherosclerotic plaque?
A pathologist view.
M.J.A.P. Daemen
Cardiovascular Research Institute Maastricht (CARIM) Universiteitssingel 50, 6229 ER Maastricht,
The Netherlands Tel +31 43-3881766
[email protected]
The clinical complications of atherosclerosis are caused by thrombus formation, which in turn
results from rupture of an unstable atherosclerotic plaque. The formation of microvessels
(angiogenesis) in an atherosclerotic plaque contributes to the development of plaques,
increasing the risk of rupture. Microvessel content increases with human plaque progression
and is likely stimulated by plaque hypoxia, reactive oxygen species and hypoxia inducible
factor (HIF) signalling. The presence of plaque hypoxia is primarily determined by plaque
inflammation (increasing oxygen demand), while the contribution of plaque
thickness (reducing oxygen supply) seems to be minor. Inflammation and hypoxia are almost
interchangeable and both stimuli may initiate HIF-driven angiogenesis in atherosclerosis.
Despite the scarcity of microvessels in animal models, atherogenesis is not limited in these
models. This suggests that abundant plaque angiogenesis is not a requirement for atherogenesis
and may be a physiological response to the pathophysiological state of the arterial wall.
However, the destruction of the integrity of microvessel endothelium likely leads to intraplaque
haemorrhage and plaques at increased risk for rupture. Although a causal relation between the
compromised microvessel structure and atherogenesis or between
angiogenic stimuli and plaque angiogenesis remains tentative, both plaque angiogenesis and
plaque hypoxia represent novel targets for non-invasive imaging of plaques at risk for rupture,
potentially permitting early diagnosis and/or risk prediction of patients with atherosclerosis in
the near future.
Contrast enhanced ultrasound for intraductal application of
contrast agent in obstructive diseases of the salivary
P. Zengel*1, V. Siedek*1, A. Berghaus*1, D.A. Clevert*2
*1 Department of Otorhinolaryngology, University of Munich, Germany
*2 Department for Clinical Radiology, University of Munich, Germany
Background: Obstructive diseases of the salivary glands are frequently caused by
Sialolithiasis; however, 5-10% of the cases cannot be diagnosed by conventional radiological
imaging or ultrasound. Using an intraductal application of a contrast agent may improve the
ability to determine the origin and location of the impediment, help identify proper treatment,
as well as allow for the tracking and evaluation of therapeutic effectiveness.
Material and Methods: The present study, performed on patients with obstructive diseases of
the salivary glands, consisted of a conventional B-scan using an linear multifrequency probe (9
Mhz), followed by a second scan using an intraductal application of ultrasound contrast agent
(SonoVue) on a high-end ultrasound (S2000, Siemens).
Subsequently, after completion of treatment, the procedure was repeated, and the results were
compared with the subjective patient assessments.
Results: The procedure improved the accuracy of the diagnosis: in two patients a stone was
detected that was not discovered by conventional ultrasound, and in five cases the duct stenosis
was clearly observable which allowed the treatment to be adapted and more objectively
Conclusion: Application of intraductal contrast agent as part of ultrasound assessment
improves diagnostic capabilities in patients with obstructive salivary gland diseases and helps
determine the best treatment. In comparison to MR-Sialography, the use of this method is
inexpensive, fast, and reproducible, thus allowing its use as an objective measure of therapeutic
effectiveness. Additionally, the examination could be applied as a periodic measure of
functional recovery of the gland after conservative treatment by analysing glands parenchyma
to legitimate the organ-preserving approach.
Lymphatic pathways visualization and sentinel node
identification with harmonic imaging and second generation
R. Lanocita, L. Suman
Radiology Dpt. Fondazione “Istituto Nazionale Tumori di Milano”
Purpose: To evaluate visualization of lymphatic pathways and sentinel node after peritumoral
injection of a second generation ultrasound echoenhancer.
Methods and Materials:
The study included 30 patient with indication for identification of sentinel node:
10 leg or arm melanomas;
5 penis carcinoma;
15 breast cancer.
(lymphoscintigraphy)has been used to compare results. Two different ultrasound equipments
were used to identify sentinel nodes: Philips IU22 with a linear 9-3Mhz probe and an Esaote
MyLab70Gold with a 9-4 linear transducer.
4.8ml of sonovue (Bracco, Milano, Italy) were injected peritumoral and the lymphatic
pathways were followed until the sentinel node was visualized. At the same time and in the
same site the technetium-labeled sulfur colloid was injected too and the sentinel node was
found with the standard technique.
Results: There was only one case of discordance between ultrasound and scintigraphic
identification. All the lymphatic ways wee explored until the first drainage node.
Conclusion: In expert hands ultrasonographic identification of sentinel node seems to be
effective. Larger series of patient are needed to confirm the method.
Nicolas Rognin1, Marcel Arditi1, Laurent Mercier1, Peter Frinking1, François Tranquart1
Anass Anaye2, Geneviève Perrenoud2, Jean-Yves Meuwly2
Bracco Research S.A. – Geneva / Switzerland
University Hospital – Lausanne / Switzerland
Introduction: Characterization of focal
Enhanced Ultrasound in Europe [1]. After
a bolus injection of contrast agent, such a
characterization is commonly guided by
Echo power [a.u.]
Healthy parenchyma
Hypervascular metastasis
healthy parenchyma. Figure 1(a) illustrates
Time [s]
known Dynamic Vascular Patterns (DVP)
of lesions with respect to surrounding
Time [s]
Figure 1: (a) Typical perfusion kinetics in healthy liver parenchyma
(blue), in hemangioma (green) and in hypervascular metastasis (red),
(b) difference signals after subtraction of the signal derived from
normal parenchyma (reference).
representative contrast-uptake kinetics as a
function of time, expressed as instantaneous echo-power (arbitrary units), obtained after linearization of
video signals. Hemangiomas (benign) are typically hyper-enhanced at all times, whereas hypervascular
metastases (malignant) usually present a hyper-enhancement (except in possible necrotic areas) during
the arterial phase followed by a hypo-enhancement in the later portal-venous phase (fast wash-out). To
make these DVP signatures more conspicuous, we demonstrated in previous work [2] the clinical
usefulness of subtracting, for each pixel signal, a reference signal derived from healthy parenchyma, as
depicted in Figure 1(b). In this particular example, the difference signal in the hemangioma exhibits a
unipolar vascular signature (strictly hyper-enhanced over time) whereas the hypervascular metastasis
difference signal has a bipolar vascular signature.
Method: The objective of the present work was to develop a new parametric imaging technique, by
mapping the vascular signatures into a single image, called DVP parametric image [3]. As summarized
in Table 1, vascular signatures are categorized into four classes according to the polarities of their
corresponding difference signals over time. Different color hues are used for displaying pixels in
different classes: (1) green hues for unipolar positive (permanent hyper-enhanced signature); (2) blue
hues for unipolar negative (permanent hypo-enhancement signature); (3) red hues for bipolar positive
(hyper- followed by hypo-enhancement signature) and (4) yellow hues for bipolar negative (hypo-
followed by hyper-enhancement signature). Contrast-sequence analyses can thus be synthesized as
spatial maps of vascular signatures, which may aid in the characterization of lesion types. Figure 3
shows how DVP parametric images allow facilitated lesion characterization as benign vs. malignant in
four typical clinical examples, with the benign cases being colored differently from the malignant ones.
The malignant lesions appear with the presence of red areas, unlike benign lesions, which appear green
or green with yellow.
Table 1: Pixel classification list according to difference signal signatures with respect to healthy parenchyma.
Pixel class name
Vascular signature
Color coding
Typically found in
(1) unipolar positive
green hues
benign lesions
(2) unipolar negative
blue hues
benign lesions
(3) bipolar positive
hyper-enhancement followed
by hypo-enhancement
red hues
malignant lesions
(4) bipolar negative
hypo-enhancement followed
by hyper-enhancement
yellow hues
benign lesions
Figure 2:
Typical clinical examples of DVP parametric images (right), with healthy parenchyma (reference) outlined in
yellow regions of interest. Contrast images at peak enhancement (left) with Philips iU22 (a) and Siemens
Sequoia 512 (b-d).
Results: The DVP parametric imaging technique was the object of a clinical assessment, including a
total of 146 focal liver lesions (113 malignant and 33 benign), imaged with real-time low-MI contrast
specific ultrasound after a bolus injection of 2.4 ml of SonoVue®. The reference diagnosis was
provided by either CT, MRI or biopsy. The DVP parametric images were read by a blinded clinician
who used the presence of red colorization as a criterion of malignancy. The resulting sensitivity and
specificity were 97% and 91%, respectively.
Discussion and conclusion: The high efficacy scores obtained with DVP parametric imaging
demonstrate the potential of the method for increasing confidence in characterizing focal liver lesions.
They compare favorably with those published in the literature (sensitivity and specificity of 91% and
86%, respectively [4]). In addition to a very simple interpretation (the presence of red areas being an
indicator of malignancy), this technique has the advantage of being less time-consuming than the usual
procedure of reviewing entire sequences of contrast images (~2 minutes). In further work, automatic
segmentation of normal parenchyma will be studied, as a way to reduce operator-dependent variability
in the resulting parametric maps, thus approaching true Computer-Aided Diagnosis of FLL by contrast
ultrasound. In the future, 4D contrast imaging is likely to become more prevalent. As the review of such
sequences may become rather tedious, the extension of DVP parametric imaging to volumetric data
may represent a very valuable tool to clinicians. This aspect will be the object of a further study.
EFSUMB Study group, “Guidelines and good clinical practice recommendations for Contrast Enhanced
Ultrasound (CEUS) – Update 2008”, Ultraschall in Med, 29:28-44, 2008.
Rognin N., Frinking P., Messager T., Arditi M., Perrenoud G. and Meuwly J.-Y. “A New Method for
Enhancing Dynamic Vascular Patterns of Focal Liver Lesions in Contrast Ultrasound”, IEEE Ultrasonics
Symp. Proc., 2007 © IEEE. doi: 546-549
Rognin N, Mercier L, Frinking P, Arditi M, Perrenoud G, Meuwly J-Y, “Parametric imaging of dynamic
vascular patterns of focal liver lesions in contrast-enhanced ultrasound”, IEEE Ultrasonics Symp. Proc.,
2009 © IEEE. doi: (in press).
Leen E., Ceccotti P., Kalogeropoulou C., Angerson W., Moug S., Horgan P., “Prospective Multicenter
Trial Evaluating a Novel Method of Characterizing Focal Liver Lesions Using Contrast-Enhanced
Sonography”, American Journal of Roentgenology, 186(6):1551, 2006.
The Effects of Platelet versus Fibrin Targeted
Microbubbles on the Success of Ultrasound and
Microbubble Mediated Thrombolysis
Feng Xie, Shunji Gao, Luke Drvol, John Lof, Omaha, NE;, UNIV NEBRASKA MED CTR,
Omaha, NE; Patrick G Rafter, Philips Healthcare, Andover, MA; Evan Unger, NuvOx
Pharma, Tuscon, AZ; Terry Matsunaga, Univ of Arizona, Tuscon, AZ; Thomas R Porter,
Although ultrasound and intravenous microbubbles (MB) have been used in recanalizing intravascular
thrombi,the success of the technique may require targeting techniques to either platelets or fibrin. The
purpose of this study was to examine the effects of platelet versus fibrin targeting on the ability of
diagnostic ultrasound and MB to dissolve thrombi without the aid of a fibrinolytic agent.
A total of 130 porcine arterial thrombi of varying age (3 or 6 hours) were treated with guided high
mechanical index (MI) impulses (1.1 MI) from a three-dimensional (3D) ultrasound. Occlusive thrombi
were embedded in branching silastic vessels (2 mm internal diameter) suspended in a tank containing
water at 37º C. Flow within the vessel was monitored using a flow pump (MasterFlex). A tissuemimicking phantom (TMP) of varying thickness (5-10 cm) was placed over the thrombosed vessel and
the 3D (X 3-1 xMATRIX array) transducer (Philips iE 33) aligned with the thrombosed vessel using a
positioning system. Diluted lipid encapsulated MB (0.5%; NuVox Pharma) that were either nontargeted or targeted to either the fibrin or glycoprotein 2b/3a receptor) were imaged with each
transducer using low MI imaging (Power Modulation) at <0.2 MI which then guided the timing of the
high MI impulses (>1.0) with either transducer. Total treatment time was 10 minutes. Percent thrombus
dissolution (%TD) was calculated by comparison of clot mass before and after treatment.
Both non-targeted and targeted microbubbles were more effective than 3D ultrasound alone in
dissolving thrombi (p<0.05; for both fibrin, platelet, and non-targeted microbubbles versus ultrasound
alone; Figure). Platelet targeting increased the degree of thrombus dissolution of three hour old arterial
thrombi at five centimeter thick TMP (p <0.05 when compared to non-targeted microbubbles), but were
not more effective than non-targeted microbubbles at a greater TMP thickness or with older age
thrombi (p=NS).
Guided high MI impulses combined with platelet or fibrin- targeted microbubbles improve thrombus
dissolution for fresh thrombi , but lose this effectiveness with greater attenuation of the ultrasound
beam or with older age thrombi.
TMBp = fibrin-targeted microbubbles; TMBf = fibrin-targeted microbubbles
NTMB= non-targeted microbubbles
- 10 -
Directing adipose derived stem cells to the area at risk in
the heart after myocardial infarction using targeted
- Development of a new molecular therapeutic technique -
A. van Dijk1,6, BA. Naaijkens1,6,7, TJA. Kokhuis2,7, M. Harteveld2, RJP. Musters3,6, VWM.
van Hinsbergh3,6, M. Helder4, O. Kamp5,6,7, N. de Jong2,6, HWM. Niessen1,2, LJM.
Dept. of Pathology, VU University Medical Center, Amsterdam, the Netherlands; 2 Dept. of
Biomedical Engineering, Thorax Centre, Erasmus Medical Centre, Rotterdam, the Netherlands; 3Dept.
of Physiology, VU University Medical Center, Amsterdam, the Netherlands; 4Dept. of Orthopaedic
Surgery, VU University Medical Center, Amsterdam, the Netherlands; 5Dept. of Cardiology, VU
University Medical Center, Amsterdam, the Netherlands; Institute for Cardiovascular Research, VU
University Medical Center, Amsterdam, the Netherland; 7Interuniversity Cardiology Institute of the
Netherlands, Utrecht, the Netherlands
Stem cell therapy is a promising tool to restore contractile function after myocardial infarction.
However, recent clinical trials show rather disappointing results with only minor improvements in
cardiac function. Therefore, stem cell research needs to return from bed to bench.
The major problem with stem cell therapy is the lack of persistence of sufficient numbers of stem cells
at the site of injury. Less than 3% of the cells remain at the infarction site after injection, independent
of the route of administration. It is not known what exactly happens to the other cells, because it is
difficult to track these cells in vivo directly after injection.
This project aims to overcome this problem by specifically targeting the stem cells to the area at risk
after myocardial infarction. Adipose-derived stem cells will be coupled to contrast microbubbles, this
stem cell-bubble complex will be targeted to specific molecules on endothelium of the injured vessel
wall, illustrated in figure 1. This will result in larger quantities of stem cells in the area at risk, thereby
improving regeneration of the heart. Besides the possibility of carrying targeting ligands on the
microbubbles, the presence of microbubbles has two other main functionalities:
1) Microbubbles can be pushed towards the vessel wall using the radiation force of diagnostic
ultrasound. This acoustic radiation force can also be applied to the stem cell-bubble complex, thereby
facilitating the binding of the stem cell-bubble complex to the endothelium.
2) Imaging and tracking of individual stem cell-bubble complexes with contrast-enhanced ultrasound,
to investigate the fate of the stem cells after injection.
- 11 -
Figure 1: Schematic drawing of a stem
cell coupled to activated endothelial cells
via dual-targeted microbubbles
- 12 -
Advances in Microbubble Applications for Treatment of
Brain Disease
Stephen Meairs, MD, PhD
Department of Neurology, Universitätsmedizin Mannheim
Heidelberg University, 68167 Mannheim, Germany
A promising research application with high translational capacity is ultrasound-targeted drug delivery to
the brain. Most substances and drugs that would be potentially useful for treatment of a variety of brain
disorders cannot be applied due to their inability to penetrate the blood-brain barrier (BBB) of the
neurovascular unit (NVU). This is particularly true for large-molecule agents such as monoclonal
antibodies, recombinant proteins, or gene therapeutics. Ultrasound can facilitate drug delivery into the
brain. Moreover, if microbubbles are combined with ultrasound exposure, the BBB can be opened
transiently by focusing ultrasound to the blood vessels with considerably lower acoustic pressures. We
have recently demonstrated successful delivery of brain-derived neurotrophic factor for manipulation of
endogenous stem cells using focused ultrasound and BG6895 microbubbles. Recently, highly
innovative microbubbles carrying nanoparticle-loaded agents have been developed. In combination
with BBB opening, this new targeting strategy will allow non-invasive therapies to the brain with
substances such as immunoglobulins, viral vectors, plasmid DNA, siRNA, mRNA and high molecular
weight drugs. We have applied this approach by targeting gene therapy to the brain with AAV vectors
coupled to these new nanoparticles.
Although it appears that minimal tissue damage occurs at appropriate acoustic power thresholds, safety
remains a concern. Our recent work demonstrates that BBB opening with ultrasound and microbubbles
affects information transfer between brain cells, in particular through alterations in gap junctions. BBB
opening in the rat leads to reorganization of gap junctional proteins in both cortical neurons and
astrocytes, as characterized by Connexin36 and Connexin43 expression, respectively. These changes
may be a cellular response to imbalances in extracellular homeostasis following blood-brain barrier
leakage. Moreover, we have shown that ultrasound-mediated BBB opening leads to an increased
ubiquitinylation of proteins in neuronal but not glial cells as soon as six hours after insonation. These
results suggest that BBB opening with ultrasound and microcubbles induces a specific cellular stress
response restricted to neuronal cells. Whether such responses are model-specific or can be reduced by
further optimizations in microbubble and ultrasound parameters require further studies.
Improved treatment of ischemic stroke with ultrasound and microbubbles in combination with
thrombolytic drugs shows great promise, but the optimal techniques, indications, and contraindications
- 13 -
have not yet been well defined. In vitro results suggesting that stabile cavitation may be more effective
than inertial cavitation for clot lysis have recently found support in a new mouse ischemic stroke model
employing focused ultrasound at low acoustic pressure in combination with novel therapeutic
microbubbles and t-PA. Application of ultrasound and microbubbles without lytic drugs may be suited
for hyperacute stroke treatment, since it appears that ultrasound may activate endogenous t-PA.
Moreover, targeting thrombus with specific immunobubbles may improve the efficacy of
sonothrombolysis. Another recent approach for clot lysis utilizes high intensity focused ultrasound in
combination with MRI (MRgFU) for targeting and monitoring of therapy. First results demonstrate
rapid lysis without thrombolytic drugs. Interestingly, this technology may have application for
treatment of intracerebral hemorrhage, i.e. removal of coagulated blood. Clinical outcome following
sonothrombolysis also may be related to other ultrasound bioeffects including BBB disruption, drug
transport, perfusion alteration, and angiogenesis. Safety remains a major concern in the further
development of ultrasound-enhanced thrombolysis and further animal work is required to define the
most promising methods for translation into a human application. Here mathematical simulations may
provide important information for fine tuning of ultrasound and microbubble parameters.
- 14 -
Sibylle Pochon1, Isabelle Tardy1, Thierry Bettinger1, Philippe Bussat1, Radhakrishna Pillai2,
Mathew von Wronski 2, Martine Theraulaz1, Patricia Emmel1, Nathalie Biolluz1, Sylvie
Pagnod-Rossiaux1 and Michel Schneider1
Bracco Research S.A., Geneva, Switzerland; 2Bracco Research USA, Princeton, NJ, USA
Introduction: Angiogenesis is the growth of new capillary blood vessels. This process occurs during
development, reproduction, and wound healing but also in pathological conditions like tumor growth
[1]. One of the most important molecular markers of angiogenesis is the vascular endothelium growth
factor receptor 2 (VEGFR2) which expression on the surface of endothelial cells has been linked to the
progression and aggressiveness of many tumor types [2]. BR55 is an ultrasound contrast agent designed
for the molecular imaging of human VEGFR2 (KDR). A common strategy for preparing targeted
contrast agents is to couple specific biotinylated antibodies to streptavidin-functionalized microbubbles
[3-6]. Although, these products are very convenient for proof-of-concept studies in animals, they are
not suitable for a human use due to the risk of initiating an immune response. BR55 is a phospholipidbased contrast-agent functionalized with a KDR-specific binding peptide [7]. A phospholipid conjugate
of the targeting peptide was designed to be incorporated in the microbubble membrane [8].
This study describes the evaluation of the binding efficiency of BR55 in vitro and its capacity for
imaging angiogenesis in vivo in rat tumor models.
Methods: BR55 microbubbles were evaluated on recombinant proteins and on cells expressing
VEGFR2 to demonstrate their binding efficiency. Specificity for the VEGF receptor-2 was determined
in competition experiments. Molecular imaging of VEGFR2 was performed with BR55 in orthotopic rat
tumor models using contrast-specific imaging mode at low acoustic power. Imaging experiments were
performed with BR55, SonoVue® and streptavidin-functionalized microbubbles coupled to an antiVEGFR2 antibody to compare the behavior of the three contrast agents.
Results: Although selected for the human receptor, the VEGFR2-binding peptide was also shown to
recognize the rodent receptor (Flk-1). Strong binding of BR55 microbubbles was observed on the
immobilized recombinant human and mouse receptors as well as on human and mouse endothelial cells.
BR55 binding was competed off by VEGF and blocked by KDR- or Flk-1-specific antibodies; thereby
demonstrating the specificity of the interaction.
- 15 -
Comparable contrast enhancement was observed in tumors at peak intensity for BR55 and SonoVue®.
Then, once unbound microbubbles had cleared from the circulation, a strong enhancement of the tumor
was obtained with BR55 whereas no significant microbubble accumulation was detected with SonoVue.
Ten minutes after BR55 injection, the enhancement in the tumor was significantly superior to that
observed in the healthy tissue. The enhancement obtained with BR55 in the tumor was not significantly
different from the one observed with antibody-coupled streptavidin microbubbles.
Conclusion: BR55, a VEGFR2-targeted ultrasound contrast agent, was shown to specifically recognize
the marker of angiogenesis and to be able to highlight malignant lesions by specific accumulation on
the tumoral endothelium. The information provided by molecular imaging combined with the
assessment of tumor perfusion may be of primary interest for characterizing tumor phenotype and
monitoring tumor response to therapy.
These results validate the concept of a targeted contrast agent based on a lipopeptide construct and open
the way for clinical applications.
P. Carmeliet "Angiogenesis in life, disease and medicine," Nature, vol. 438, pp. 932-936, 2005.
D. J. Hicklin and L.M. Ellis."Role of the vascular endothelial growth factor pathway in tumor growth and
angiogenesis," J. Clin. Oncol., vol. 23(5), pp. 1011-27, 2005.
G. Korpanty , J. G. Carbon, P. A. Grayburn, et al. "Monitoring response to anticancer therapy by targeting
microbubbles to tumor vasculature," Clin. Cancer Res., vol. 13, pp. 323-330, 2007.
J. K. Willmann, R. Paulmurugan, K. Chen, et al. "US imaging of tumor angiogenesis with microbubbles
targeted to vascular endothelial growth factor receptor type 2 in mice," Radiology; vol. 246, pp. 508-518,
M. Palmowski, B. Morgenstern, P. Hauff, et al. "Pharmacodynamics of streptavidin-coated cyanoacrylate
microbubbles designed for molecular ultrasound imaging," Invest. Radiol., vol. 43, pp. 162-169, 2008.
A. Lyshchik, A. C. Fleischer, J. Huamani, et al. "Molecular imaging of vascular endothelial growth factor
receptor 2 expression using targeted contrast-enhanced high-frequency ultrasonography," J. Ultrasound Med.,
vol. 26, pp. 1575-1586, 2007.
A. Shrivastava, M. A. von Wronski, A. K. Sato, et al. "A distinct strategy to generate high-affinity peptide
binders to receptor tyrosine kinases," Protein Engineering, Design & Selection, vol. 18, pp. 417–424, 2005.
Pillai R, Marinelli E, Fan H et al. A phospholipid-PEG2000-conjugate of a KDR-targeting heterodimer
peptide for contrast enhanced ultrasound imaging of angiogenesis. Bioconjugate Chem. Submitted
- 16 -
Tumor cell killing efficiency of doxorubicin-liposome loaded
microbubbles after ultrasound exposure
Lentacker I., Geers B., Demeester J., De Smedt S.C., Sanders N.N.
Ghent Research Group on nanomedicine, Department of pharmaceutical sciences, Ghent University,
Harelbekestraat 72, 9000 Gent, Belgium
The aim of this study was to design doxorubicin (DOX)-liposome loaded microbubbles and evaluate
their tumor cell killing efficiency in vitro.
DOX-liposome loaded microbubbles were prepared by attaching Doxil-like liposomes to the surface of
lipid microbubbles via avidin-biotin interaction (Figure 1).
Figure 1
Melanoma cells were seeded in Opticells and exposed to DOX-liposomes and DOX-liposome
loaded microbubbles without and with ultrasound exposure (USE) (1MHz, 50%DC, 30s). Exposure of
the cells to DOX-liposome loaded microbubbles resulted in a much higher tumor cell killing efficiency
than exposure to DOX-liposomes (Figure 2). We did not see an outspoken improvement of cell killing
by DOX-liposomes when ultrasound was applied.
We also studied the intracellular localization of DOX after 4 hours incubation time with DOXliposomes or DOX-liposome loaded microbubbles and USE. The DOX was almost exclusively present
in the nuclei of cells treated with DOX-liposome loaded microbubbles, whereas the DOX was found in
both, cytoplasm and nucleus of cells treated with DOX-liposomes (Figure 3). Additional experiments
revealed that at least two different mechanisms are responsable for the high tumor cell killing efficiency
of DOX-liposome loaded microbubbles after USE. During implosion of the microbubbles, liposomes
- 17 -
are damaged and free DOX is released, which is immediately taken up through cell membrane
Lentacker I., Geers B., Demeester J., De Smedt S.C., Sanders N.N. Design and evaluation of doxorubicin containing
microbubbles: cytotoxicity and mechanisms involved. Molecular Therapy advance online publication. July 21th 2009. Doi:
Figure 2
Figure 3
- 18 -
Role of CEUS in Endovascular Aneurysm Repair (EVAR)
procedures and during the follow-up
D.A. Clevert
Department of Radiology, Klinikum Grosshadern, University of Munich, Munich, Germany
Abnormalities of the abdominal aorta may represent a diagnostic challenge in patients both
with acute and chronic clinical symptoms. In addition to the examination using color coded
duplex ultrasound, contrast enhanced ultrasound (CEUS) with low-mechanical-index (low MI)
may contribute in achieving a precise diagnosis. Most of these patients will be treated by
endovascular aneurysm repair. Endoleaks following endovascular aneurysm repair (EVAR) are
common. Contrast-enhanced ultrasound (CEUS) is a promising new method for the diagnosis
and follow-up of endoleaks. CEUS with SonoVue® allows a rapid and noninvasive diagnosis in
the follow-up after EVAR. The sensitivity and specificity of conventional ultrasound,
compared to the MS-CTA is estimated up to 33-63% and 63-93%. These values can be
increased through the use of CEUS in up to 98-100% (sensitivity) and 82-93% (specificity).
This presentation describes the etiology, classification and importance of different
abnormalities of the abdominal types and endoleaks. The value of CEUS in this clinical
scenario will be discussed.
- 19 -
Convertible Liquid Droplets for Ultrasound Contrast
Nikita Reznik1, Ross Williams2, Naomi Matsuura1,2 and Peter N. Burns1,2
University of Toronto, Toronto, Canada
Sunnybrook Health Sciences Centre, Toronto, Canada
One of the strengths of microbubbles is that their relatively large size confines them to the intravascular
space, offering many opportunities to make measurements that are difficult to achieve with the
diffusible tracers for other imaging modalities. But their size also creates some important limitations in
their potential application. For example, bubbles cannot be used to sense changes in vascular
permeability, nor be usefully associated with ligands which target sites outside the vascular system.
Furthermore, potentiation of ablative therapies like HIFU with bubbles is complicated by the fact that
the bubbles fill the perfused space in normal tissue at the same time that they are present in the target
Although it is quite difficult to make bubbles as small as the 200nm or so required for extravasation, it
is possible to make emulsions of liquid droplets of this size with relative ease. Such droplets, even of
low acoustic velocity liquids such as perfluorocarbons (PFC), scatter only weakly and have been shown
to behave linearly at least up to about 50MHz (1). They would therefore need to be present in high
concentrations in tissue or blood to be detectable and are thus are not promising as ultrasound contrast
agents. However, if droplets are made of PFC liquids that have a boiling point near that of the ambient
temperature, they can be vaporised by exposure to ultrasound energy. Thus nano- (or, more accurately,
submicron-) droplets could be injected, diffuse selectively into tissue fed by hyperpermeable vessels
such as tumour vessels, then be converted into vapour by ultrasound activation. The resulting gas may
be detectable using conventional pulse-echo, by acoustic emission or, if we are lucky, by nonlinear
resonant oscillation. If this goal could be achieved, droplets could be attached by ligands to
extravascular targets which could then be detected or might be activated into gas which potentiates
ultrasound therapy at the focus of the HIFU beam without affecting thermal absorption elsewhere in
tissue. Our investigations centre on the objective of formulating and understanding the physical
behaviour of activated droplets. We study the size, stability and echogenicity of the microbubbles newly
created from emulsions of differing PFC liquids, coated with a surfactant shell. We use optical and
acoustic methods to study properties which are needed for successful nonlinear ultrasound imaging in
the first second after conversion.
Droplets of dodecafluoropentane (DDFP) coated with fluorosurfactant (Zonyl FSP), with
diameter of 415 ± 20 nm, were vaporised in a 200 µm polyethylene tube with a single 10-cycle pulse
from a focused 7.5 MHz transducer. Subsequent acoustic detection was performed with a series of 10cycle pulses at 1.75 MHz and peak negative pressure (Pneg) of 120 kPa, at times from 1ms to 1s after
- 20 -
excitation. Converted droplets were also studied under a microscope (4 pixels per micron resolution)
connected to a camera (which in Rotterdam we must call low speed) operating at 1000 fps for time
periods of up to 1s after excitation.
Echoes from droplets excited at Pneg > 1.7 MPa showed a significant increase in power at both the
fundamental (1.75MHz) and second harmonic
(3.5MHz) bands 1ms after excitation, indicating
oscillation (Fig. 2). Typical power spectra of low
intensity detection pulse echoes from the droplet
sample before and after excitation are shown in Fig.
3. There is a significant increase in both the
fundamental (1.75 MHz) and the 2nd harmonic (3.5
Figure 1. Size distribution of the droplet suspensions measure
with dynamic light scattering. Mean droplet diameter prior to
MHz) component of the detected signal. In
addition, the signal spectrum changes over time during the 1s time interval after excitation. The power
spectrum of the echo detected 200 ms after excitation exhibits a further increase in the fundamental
component. However, the power in the 2nd harmonic band is reduced. The characteristic increase in
power of the fundamental band and decrease in power at the harmonic band is apparent in
approximately the first 100 ms. After this initial evolution, the signal appears to be relatively stable for
the following 900 ms. Fig. 4 shows the relative integrated backscatter from the droplet sample and
pulse-inversion imaging power as a function of time. It is apparent that while the acoustic cross section
is increased, integrated pulse-inversion power seems to decrease. The overall increase in echogenicity
Figure 3. Power spectra of the low intensity detection
signal scattered from the droplet sample before and after
Figure 2. Power in the fundamental and harmonic bands
of the scattered detection signal and different time points.
- 21 -
suggests inception of ultrasound scatterers such as microbubbles in the sample as a result of the high
intensity excitation ultrasound pulse. The increase in the 2nd harmonic band suggests the the newly
created bubbles oscillate nonlinearly. Change in the scattered echo over time is characteristic of
evolution in size distribution of the bubble populations. The decrease in the nonlinear response of the
bubbles suggests that bubbles might grow through their resonance size, associated with the frequency of
the detection pulse (1.75 MHz). Optical observations will be shown which seem to confirm this.
The ability of post-conversion droplets to scatter
ultrasound non-linearly allows use of contrast
inversion imaging, along with high intensity
diagnostic applications. Moreover, simultaneous
acoustic cross section increase and power decrease
in the 2nd harmonic band in the first 1 s after
conversion is different from the usual behaviour of
agents. Such characteristic behaviour might be used
Figure 4. Relative acoustic cross section and
pulse-inversion processed echo power as a function
of time for post-conversion droplet sample.
to develop an imaging technique with both regular
and nonlinear B-mode for converted-droplet-specific imaging.
Suspensions of submicron DDFP droplets were successfully stabilised by fluorosurfactant coating
through the process of high pressure emulsification. Droplets remain in liquid form when raised to 37°C
in a superheated state.
External agitation by high intensity ultrasound pulse triggers the droplets to undergo phase change,
expanding by approximately 5 times in diameter, effectively converting into microbubbles. In the first
100 ms after vaporisation, the bubbles experience additional size increase due to uptake of dissolved
gas from the surround liquid, causing a further 4x increase in the bubble diameter. After the initial
growth, the bubbles were shown to remain stable for time periods of at least 900 ms, rendering them
sufficiently stable to be applicable for diagnostic ultrasound imaging.
Post-conversion droplets experience a significant increase in echogenicity. Vaporised droplets
were shown to scatter ultrasound both in the fundamental and the harmonic bands of the incident pulse,
enabling their detection with nonlinear imaging techniques. Furthermore, bubble growth due to uptake
of gas from the host liquid induces a characteristic change in acoustic properties of the bubbles,
increasing the acoustic cross-section while simultaneously decreasing nonlinear scattering power.
Converted droplets may not only increase contrast in the regions of interest on an ultrasound image, but
might also be selectively detected with a converted droplet specific imaging technique.
- 22 -
Flordeliza S. Villanueva , Huili Fu, Jianjun Wang, Xioping Leng,
Andrew Fisher, and Xucai Chen
Center for Ultrasound Molecular Imaging and Therapeutics
University of Pittsburgh Medical Center , Pittsburgh, PA
BACKGROUND: The acute and long-term location and viability of stem cells (SCs) used in reparative
cardiovascular therapies is poorly understood due to the limited methods available for safely and noninvasively serially tracking the cells in vivo. It is hypothesized that ultrasonic SC tracking is achievable
using mesenchymal stem cell (MSC)-internalized, slowly degrading, polymer microbubbles (MBs).
METHODS: Human-bone marrow derived MSCs were cultured to confluence and dwelled with
perfluorocarbon gas-filled Bodipy-labeled polymeric microbubbles for 14 hours, washed to remove free
MBs, and trypsinized for acoustic testing in suspension. MB-labeling of MSCs was confirmed by
confocal microscopy. Acoustic activity was confirmed by spectral analysis of free MB, control MSCs
(not exposed to MBs), and MB-labeled MSCs responding to 2.5MHz tone-burst ultrasound at various
powers and with second harmonic and contrast pulse sequence (CPS) imaging at 7MHz and a
mechanical index of 0.97. Video intensity was averaged over 25 frames per capture. A LIVE/DEAD
Viability kit and flow cytometry were subsequently used to confirm viability.
RESULTS: Spectral analysis of signals from free MB and MB-labeled MSC suspensions demonstrated
non-linear acoustic behavior attributable to their sustained gas content. Control MSCs displayed only
low linear acoustic behavior. Confocal microscopy exhibited several MBs associated to most MSCs.
Flow cytometry confirmed viability of 95% of MB-MSC complexes, which was no different from
control MSCs. Video intensity of MB-labeled MSCs was significantly higher than control MSCs in
both harmonic (18.10±6.82 vs. 2.42±1.21, respectively, p<0.01) and CPS (18.98±2.93 vs. 0.39±0.20,
respectively, p<0.005) images.
CONCLUSIONS: Using a polymer contrast agent microbubble label, we have developed a method for
visualizing MSCs with non-linear clinical ultrasound. For in vivo application, MSC labeling by MBs is
theorized to permit the retention of acoustic activity and cell viability once the stem cells have been
accepted by a host tissue. Because the MBs degrade slowly, this approach may permit non-invasive
serial in vivo tracking of MSC fate over a protracted period, and thus facilitate optimization of cell
therapy strategies.
- 23 -
Experimental investigation of microbubble response to
ultrasonic pulses used in therapeutic applications
Christophoros Mannaris1, Kypros Stylianou1, Nico de Jong2 and Michalakis Averkiou1
1-Dept. of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus
2-Dept. of Biomedical Engineering, Thoraxcentre, Erasmus MC, Rotterdam, The Netherlands
Research interest in the area of ultrasound contrast agents is shifting towards therapeutic applications
such as targeted drug delivery, gene and DNA transfection [1], sonothrombolysis [2], and sonoporation
[3]. To date however, the microbubble response to therapeutic-type excitations has not been studied in
detail and it is not well understood. Often the conditions used in published works are simply a case of
trial and error during which the microbubbles are subjected to pulses ranging from a few cycles [1] up
to several thousand cycles [4].
In the present work, we present an in-vitro experimental method developed to examine the response of
microbubbles to ultrasonic pulses of various amplitudes, pulse duration and pulse repetition frequency
(PRF) in an attempt to find the optimal conditions to use in therapeutic applications. Two in-vitro
setups are considered, a) with the microbubbles freely suspended in deionized water and b) with the
microbubbles enclosed in a capillary.
Materials and methods
A schematic of the ultrasonic enclosure designed to accommodate two single element circular
transducers (Panametrics-NDT, Waltham, Massachusetts, USA) is shown in figure 1. A focused 1.0
MHz transducer was used as the transmitter and another 2.25 MHz as the receiver. Care was taken so
that the foci of the two transducers are placed in the same spot. An acoustic absorbing material lined the
walls to minimize reflections and contamination of the scattered signal from microbubbles. In the setup
with freely suspended microbubbles, a dilute concentration (36 bubbles/μL) of SonoVue (Bracco,
Geneva, Switzerland) was used in order to achieve response from single microbubbles. Before each
excitation, the solution was stirred and allowed to settle, enough for the bubbles to stop moving but not
float. In the capillary setup, the microbubbles were allowed to flow in a 200 μm acoustically transparent
cellulose capillary which was placed at the overlapping foci of the two transducers. This setup was
designed to better imitate in-vivo conditions of microbubbles flowing in the microcirculation. Before
each excitation, the flow was stopped for the bubbles to remain still inside the capillary. The pulse
settings studied are: number of cycles (10-2000), MI (0.05-1.1) and PRF (0.05-1.0 KHz). For all
- 24 -
experiments, an iU-22 scanner (Phillips, Bothell, WA, USA) was used to verify the uniformity of the
solution. An example of the microbubble-filled capillary moments after a therapy pulse is fired is
shown in fig.2. The area where the bubbles were destroyed is marked with a circle.
Figure 1: Schematic of enclosure
Figure 2: Microbubble disruption in capillary
due to therapy pulse firing
Data analysis and results
The response of freely suspended microbubbles to a series of 1 MHz, 10-cycle tone bursts spaced 20 ms
apart (PRF = 50 Hz) is shown in figure 3. MI 0.1, 0.2 and 0.4 are shown in fig.3 (a)-(c), respectively.
The horizontal axis is time in milliseconds and the vertical axis is the scattered intensity in mV. At MI
0.1, the amplitude of response remains unaltered suggesting that the microbubble remained intact for
the duration of the experiment. At MI 0.2, there’s a gradual decrease in amplitude of the response,
suggesting disruption of the microbubble and gradual diffusion of the gas. Finally at MI 0.4, there is no
response from the 2nd burst (detected signal is a reflection from the walls) suggesting that the
microbubble is destroyed by the 1st pulse and completely diffuses away within 10 ms.
The response of microbubbles to such short tone bursts is of course very well known and previously
published. The response to much longer pulses similar to those used in therapy, however, is not yet
clearly understood. Figure 4(a) shows the response to a series of 500-cycle bursts at MI 0.2. At this
pressure, bubble destruction and gradual diffusion is expected. Instead the signal seems to increase with
time. Microbubbles are probably moving from the perimeter to the center of the detection area. Similar
results that suggest motion of the microbubbles were seen even at lower pressures. The bubble response
to 500-cycle bursts of MI 0.1 and 2000-cycle bursts of MI 0.05 are shown in figs. 4 (b) and (c),
respectively. At such low pressures, the scattered signal intensity was expected to stay constant
throughout the experiment instead of fluctuating considerably as seen in the figures. Microbubbles that
move in and out of the center of the detection area can explain the fluctuations in both these cases. The
motion of microbubbles during these therapy-type excitations can be attributed to acoustic streaming,
the motion of the fluid in the direction of propagation of the sound [5]. Streaming was verified with
ultrasound imaging where video loops of moving microbubbles during the excitations have been
- 25 -
recorded. Since any motion of the microbubbles during an excitation affects the results, longer bursts
using the freely suspended microbubbles setup were not investigated.
Scattered intensity (mV)
Scattered intensity (mV)
Figure 3: Scattered response for 1.0 MHz, 10
cycles, MI (a) 0.1, (b) 0.2, (c) 0.4
Figure 4: Streaming; (a) 500 cycles, MI 0.2, (b) 500
cycles, MI 0.1 and (c) 2000 cycles, MI 0.05
Streaming is successfully eliminated in the capillary setup and thus longer tone burst may be
investigated. The capillary set-up better resembles in-vivo conditions where streaming does not occur in
the microcirculation and microbubbles flowing in capillaries are not allowed to be “pushed” by the
ultrasound. Figure 5 shows the response of microbubbles in the capillary to a series of 200-cycle tone
bursts spaced 10 ms apart (PRF=100 Hz). MIs 0.1, 0.2 and 0.4 are shown in fig. 5 (a)-(c) respectively.
In a similar fashion to the freely suspended bubbles, we observe that MI 0.1 is non-destructive
(intensity remains constant with time), MI 0.2 is semi-destructive (intensity gradually decreases), and
MI 0.4 is highly destructive (bubble disappears by the 2nd pulse). At MI 0.4 the bubble scattered signal
disappears completely half-way through the 1st pulse (i.e. within 100 cycles or 100 μs). Two regions are
selected within the 1st pulse, one at the beginning and one at the end. A Blackman-Harris window is
applied to the selected regions and their frequency content is plotted. The time domain and frequency
spectrum of the first region is shown in figs. 5(d) and (e), respectively whereas the spectrum of the 2nd
region is shown in fig. 5(f). The absence of higher harmonics in fig. 5(f) verifies that the bubbles in the
detection area have been destroyed.
Discussion The response of microbubbles to a large range of pulse settings has been studied in two
different experimental setups: (a) with the microbubbles freely suspended in deionized water and b)
with the microbubbles enclosed in a capillary. We have shown that acoustic streaming occurs in the
freely suspended microbubbles setup (during long, high energy pulses) and induces motion of the
microbubbles that affects the results. Experimental setups similar to the one described here where the
- 26 -
microbubbles are freely suspended in a medium (e.g. microbubbles in opti-cell) probably suffer from
the similar problems.
Enclosing the microbubbles in a cellulose capillary eliminates acoustic streaming and allows a more
accurate observation and measurement of the bubble response, while at the same time closely resembles
the in-vivo scenario of microbubbles in the microcirculation. An MI less than 0.2 was found to be nondestructive while destruction begins at an MI 0.2. At MIs greater than 0.4, the microbubbles were
destroyed and diffused within 100 cycles or 100 μs irrespective of the pulse length (number of cycles).
Hence a question arises whether the use of longer ultrasound pulses at such high pressures is beneficial
or not. The results shown in the present work refer to Sonovue. Experiments with polymer shelled and
drug loaded microbubbles are underway.
time (ms)
Scattered Intensity (mV)
time (ms)
Figure 5: 200 cycles, PRF=100 Hz, MI = 0.1(a), 0.2(b), 0.4(c). (d)-(e) time domain and spectrum of 1st selected region of pulse
at MI 0.4, (f) spectra of 2nd selected region
P. A. Dijkmans, L. J. Juffermans, R. J. Musters, A. van Wamel, F. J. ten Cate, W. van Gilst, C. A. Visser, N. de
Jong, and O. Kamp, "Microbubbles and ultrasound: from diagnosis to therapy," Eur J Echocardiogr, vol. 5, pp. 24556, 2004.
C. A. Molina, M. Ribo, M. Rubiera, J. Montaner, E. Santamarina, R. Delgado-Mederos, J. F. Arenillas, R. Huertas,
F. Purroy, P. Delgado, and J. Alvarez-Sabin, "Microbubble administration accelerates clot lysis during continuous 2MHz ultrasound monitoring in stroke patients treated with intravenous tissue plasminogen activator," Stroke, vol. 37,
pp. 425-9, 2006.
A. van Wamel, K. Kooiman, M. Harteveld, M. Emmer, F. J. ten Cate, M. Versluis, and N. de Jong, "Vibrating
microbubbles poking individual cells: drug transfer into cells via sonoporation," J Control Release, vol. 112, pp.
149-55, 2006.
A. Ghanem, C. Steingen, F. Brenig, F. Funcke, Z. Y. Bai, C. Hall, C. T. Chin, G. Nickenig, W. Bloch, and K.
Tiemann, "Focused ultrasound-induced stimulation of microbubbles augments site-targeted engraftment of
mesenchymal stem cells after acute myocardial infarction," J Mol Cell Cardiol, vol. 47, pp. 411-8, 2009.
H. C. Starritt, F. A. Duck, and V. F. Humphrey, "An experimental investigation of streaming in pulsed diagnostic
ultrasound beams," Ultrasound Med Biol, vol. 15, pp. 363-73, 1989.
- 27 -
SPECT/CT Imaging and Quantification of Focused
Ultrasound Induced Extravasation
Sanches, Pedro1; Rossin, Raffaella2; Böhmer, Marcel2; Tieman, Klaus3; Grüll, Holger1, 2
Biomedical NMR, Eindhoven University of Technology; 2Biomolecular Engineering, Philips Research
Eindhoven; 3Department Cardiology and Angiology, Hospital University Muenster
Introduction: Focused ultrasound allows to locally trigger drug delivery with a high spatial control.
Circulating ultrasound contrast agents (microbubbles) burst upon focused ultrasound exposure, which
leads to transient openings in the endothelium and creates transient pores in cell membranes. These
effects allow for extravasation of macromolecular drugs into surrounding tissues and/or uptake into
cells that otherwise would be confined to the vascular system (Ferrara 2008). The temporal evolution
and fate of the pores in the endothelial barrier is not well known but indications are obtained that the
effect lasts for more than 1 hour (Hancock et al. 2009). In this study we used small animal Single
Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) to image and quantify
the kinetics of extravasation of radiolabeled albumin in skeletal muscle in mice, after treatment with
focused ultrasound and microbubbles.
Methods: Bovine serum albumin coupled to diethylene triamine pentaacetic acid groups (DTPA-BSA)
was synthesized and radiolabeled with 111In for use as an extravasation agent. Microbubbles were used
at a concentration of 1x109 microbubbles/mL in saline. The ultrasound setup consisted of a focused
ultrasound probe (Therapy and Imaging Probe System, Philips) with a focus of 1x1x6mm which was
used under ultrasound image guidance (HDI5000, Philips). All experiments were performed on female
Swiss mice weighing 24 to 30g.
Immediately after microbubble intravenous bolus injection (50µL) the hind limb skeletal muscle in
mice was exposed to focused ultrasound (1.2MHz, 2MPa, 10000cycles, Pulse Repetition Frequency
0.2Hz). Approximately 20 minutes after ultrasound treatment, 30 to 50MBq of
(200µg) were intravenously injected followed by SPECT/CT scans at different time points. A postmortem biodistribution study was performed for every animal.
Results: 7 minutes post-injection (p.i.) of radiolabeled albumin, localized extravasation of albumin can
be imaged with SPECT. Consecutive scans show an increase in signal in the treated area up to 60min
p.i. (Figure 1). Biodistribution data show values of up to 3.2 %ID/g accumulation in treated areas and
0.2 %ID/g in control areas, leading to a ratio treated/non-treated muscle of approx. 16.
- 28 -
Conclusions: Our results demonstrate that non invasive imaging of ultrasound-induced extravasation in
mice with SPECT/CT is a useful tool as it allows to image extravasation and to follow the kinetics of
the process. Another important finding is that localized extravasation of albumin (~7nm) increases over
a period of 1h after ultrasound treatment, as evidenced by SPECT imaging.
Results show that SPECT is a useful tool to follow and quantify ultrasound induced drug delivery in
vivo in combination with radiolabeled drugs. This important tool will be used in future preclinical
studies to probe the time and size characteristics of pores in the endothelial barrier and relate them to
the respective ultrasound delivery characteristics.
Figure 1. SPECT/CT images. A – dynamic scan 7min p.i. B – static scan 1h p.i. Green
circle marks treated area in left limb. Notice signal difference to the same area in right
Ferrara, KW, Driving delivery vehicles with ultrasound. Adv Drug Delivery Rev 2008, 60 (10), 10971102
Hancock, H. A.; Smith, L. H.; Cuesta, J.; Durrani, A. K.; Angstadt, M.; Palmeri, M. L.; Kimmel, E.;
Frenkel, V., Investigations into pulsed high-intensity focused ultrasound-enhanced delivery: preliminary
evidence for a novel mechanism. Ultrasound Med Biol 2009, 35, (10), 1722-36.)
This study is part of the FP7 European Project Sonodrugs (ref. 213706).
- 29 -
The origin of “compression only” and enhanced
subharmonic behaviour of phospholipid-coated ultrasound
contrast agent microbubbles
Jeroen Sijl, Marlies Overvelde, Benjamin Dollet, Valeria Garbin, Timo Rozendal, Nico de
Jong, Detlef Lohse and Michel Versluis
Unlike tissue, coated microbubbles are able to scatter sound subharmonically. Therefore, subharmonic
behavior of coated microbubbles can be used to enhance the contrast in ultrasound contrast imaging.
present a study into the origin of the subharmonic and “compression only“ behavior of
phospholipid coated microbubbles. The Brandaris ultrahigh-speed camera is exploited to investigate the
effect of the amplitude and the frequency of the driving pressure on both the subharmonic and
“compression only” behavior of individual differently sized BR14 (Bracco Research S.A., Geneva,
Switzerland) coated microbubbles with initial radii between 2.2 and 4.8 micrometer. The experimental
results show that the phospholipid shell of the microbubbles induce “compression only” behaviour and
can enhance subharmonic behavior of coated bubbles as compared to uncoated bubbles. Subharmonic
oscillations are observed to occur already for driving pressures as low as 5 kPa. This is in contradiction
with the assumption that the damping induced by the phospholipid shell reduces this non-linear
behavior. An explanation is presented for the enhanced subharmonic and “compression only” behavior
of phospholipid coated bubbles. Through a weakly non-linear analysis of a general form of the
numerical model describing the dynamics of coated bubbles it is shown that a shell elasticity that
rapidly changes with bubble oscillation amplitude enhances both the subharmonic and “compression
only”behavior. This rapid change in elasticity is hypothesized to result from the 3D-collapse of the
phospholipid monolayer coating of the bubble, i.e. buckling of the phospholipid shell. The agreement
that is found between the experimentally determined radial dynamics and the numerical model of
Marmottant et. al.1 that takes into account the buckling of the shell confirms this hypothesis. The
comparison between the numerical model and the experimental results shown that both the
subharmonic and “compression only” behavior of phospholipid coated microbubbles are strongly
determined by the initial surface tension of the phospholipid coated microbubble. A bubble with an
initial surface tension close to zero, i.e. a bubble of which the surface is initially completely saturated
with phospholipids shows strong subharmonic and “compression only” behavior at low acoustic driving
pressure amplitudes. In contrast, a bubble of which the surface is initially unsaturated with
phospholipids shows no subharmonic behavior and less “compression only” behaviour.
- 30 -
1) P. Marmottant, S. van der Meer, M. Emmer, M. Versluis, N. de Jong, S. Hilgenfeldt, and D. Lohse, “A
model for large amplitude oscillations of coated bubbles accounting for buckling and rupture”, J.
Acoust. Soc. Am. 118, 3499 – 3505 (2005).
An example of the radial response of a phospholipid coated microbubble, recorded with the Brandaris ultrahighspeed camera, showing “compression-only” behaviour. The left figure shows the radius time curve, and on the
right we observe the corresponding optical images, showing buckling of the phospholipid shell.
A radius time curve and the corresponding Fourier transform of a phospolipid coated microbubble as recorded
with the Brandaris ultrahigh-speed camera showing subharmonic behaviour for a driving pressure with a
frequency of 2.4 MHz and an amplitude as low as 40 kPa. A good agreement was found between the experimental
curve (black) and the numerical model as proposed by Marmottant et al.1 (red) only if the initial surface tension of
the bubble was assumed to be close to zero σ (R0) = 0 N/m, i.e the bubble surface is initially completely saturated
with phospholipids and close to the buckling state.
- 31 -
Follow-up of Cryoablation in kidney cancer: CT versus
Hessel Wijkstra
AMC University Hospital, Amsterdam, the Netherlands
Kidney and renal pelvic cancers represent approximately 3% of all cancer cases, thus accounting for
~40,000 new cases and ~13,000 deaths in the United States per year. The most frequent type of tumor,
occurring in about 80% of the cases, is renal-cell carcinoma, and ~60% of these tumors are found
incidentally. A suspect lesion is often observed during ultrasound studies, and a contrast-enhanced CT
(or MRI) scan is performed to confirm the diagnosis. Contrast-enhanced CT shows the perfusion
pattern of the lesion, and this information is used to characterize the mass. CT is considered the primary
imaging modality in the diagnosis of RCC.
The gold standard in the treatment of renal masses is still the radical nephrectomy, however, it is more
and more replaced by a partial nephrectomy, especially for small renal masses. Radiofrequency ablation
(RFA) and cryoablation are new minimally invasive therapeutic options for small masses (~diameter <4
cm). Because the tumor is not removed when using these ablative treatment methods, the viability of
this tissue needs to be assessed. Histological evaluation would be the best option to assess the efficacy
of the treatment. However, the diagnostic value of renal biopsies is too low. Follow-up of cryoablation
with biopsies is even more unreliable, because of the expected small recurrences or residual tumors.
Ablation of the tumor results in the destruction of tissue and thus in vascular damage, resulting in
necrosis of the tumor tissue. The mainstay of evaluating ablative treatments therefore focuses on
evaluating the absence of perfusion. Contrast-enhanced CT is able to visualize these perfusion defects,
and is currently the reference standard in the follow-up of ablative treatments.
For diagnosis one or more contrast CT’s are performed. The general follow-up scheme of cryoablation
consists of a contrast CT at 3,6,9,12,18,24 months and thereafter once a year. This implies that within 5
years most patients will undergo at least 10 contrast CT’s. Because of the potential hazards involved
with radiation exposure, especially for the younger patients, replacement of all or at least a majority of
these contrast CT’s by CEUS would, in potential, be very beneficial.
Contrast-enhanced ultrasonography (CEUS) can be used to examine the perfusion patterns of lesions,
and therefore could also be used in diagnosis and follow-up of treatment, without radiation exposure.
- 32 -
Two main side effects of the contrast agents used with CT are allergic reactions and damage to the
kidneys. CT contrast allergies are rare, but may be serious if they occur. Contrast may also be damaging
to the kidneys, especially in patients with kidney problems. Ultrasound contrast agents do not have
these side effects, and are thus are preferred above CT contrast.
We currently are comparing CEUS with contrast CT imaging (gold standard) in the diagnosis and
follow-up of treatment of small renal masses. Whenever the patients undergo a contrast CT, they are
also imaged with CEUS.
Over 100 patients, treated with cryoablation, have been included in this study, with a follow-up period
up to three years.
In this presentation, the use of CEUS for the follow-up of cryoablation will be discussed. The
conclusion is that we expect that at least the majority of contrast CT’s can be replaced by CEUS,
lowering the radiation exposure and possible side-effects of the CT contrast agents.
- 33 -
Paul Sidhu
Ultrasound is the imaging modality of choice for the investigation of scrotal abnormalities, the
addition of colour and spectral Doppler ultrasound an important adjuvant. Rarely does the
examiner have to resort to magnetic resonance imaging to delineate the abnormality and obtain
a diagnosis. With the advent of microbubble contrast agents a new pathway in the diagnostic
workup of patients is available. The diagnostic challenges presented by some lesions of the
scrotum will be reviewed. A demonstration of the effectiveness of microbubble contrast
ultrasound at improving the diagnostic accuracy, reducing delays and preventing unnecessary
operations will be discussed.
Areas of vascularity and non-vascularity present important
parameters in the diagnostic pathways, and contrast enhanced ultrasound provides a useful tool
in this situation. By improving operator confidence, a correct diagnosis is achieved, further
dispensing with the need for further imaging.
- 34 -
The future of prostate cancer diagnosis
Ferdinand Frauscher, MD
Department of Radiology
Medical University Innsbruck, Austria
Ultrasound (US) is a widely used and well tolerated imaging modality for evaluation of the
prostate. Recent technical advances of US applications have enabled new aspects in the analysis of the
prostate. Structural analysis is applied for measurement of prostate volume, studying of echo texture,
and the illustration of tissue stiffness or elasticity. Functional analysis contains the illustration of
macrovascularity and microvascularity, which are indicators of tissue perfusion. The purpose is to
provide an overview of the use of ultrasound imaging techniques and to discuss current trends and
future directions.
Materials and Methods:
We compared contrast enhanced ultrasound targeted biopsy (CB) of the prostate with gray scale
ultrasound guided systematic biopsy (SB). Two hundred thirty male screening volunteers were
included. The detection rate was 30%, including 24% by CB and in 23% by SB. Cancer was detected
by CB alone in 7% and by SB alone in 6% of the patients. The detection rate for CB cores (10% of
cores) was significantly better than for SB cores (5% of cores). CB in a patient with cancer was 2.6-fold
more likely to detect PCa than SB. CB detected as many cancers as SB with fewer than half the number
of biopsy cores.
Furthermore we evaluated CB versus SB for the impact on Gleason score findings. The study
included 690 men and Sonovue (Bracco, Italy) was used. PCa was identified in 221 of 690 subjects
(32%) with a mean PSA of 4.6ng/ml. The Gleason score of all 180 cancers detected by CB targeted
biopsy was 6 or higher (mean 6.8). The Gleason score of all 166 cancers detected by SB ranged
between 4 and 6 (mean 5.4). CB detected significantly higher Gleason scores compared with SB.
Though CB may allow identification of more aggressive cancers, which is important for defining
prognosis and deciding treatment.
Preliminary data on the use of cadence-contrast pulse sequencing (CPS) technology, for
detecting prostate cancer have shown, that cancer was detected in 35 of 44 patients (80%), with a mean
PSA level of 3.8 ng/mL. Lesions suspicious on CPS showed cancer in 35 of 44 patients (80%) and
- 35 -
systematic biopsy detected cancer in 15 of 44 patients (34%). CPS-targeted cores were positive in 105
of 220 cores (47.7%) and in 41 of 440 systematic biopsy cores (9.3%) (P < 0.001). Therefore CPS
enables excellent visualization of the microvasculature associated with prostate cancer, and can
improve the detection of prostate cancer compared with systematic biopsy.
Currently 10 to 12 TRUS-guided prostate biopsies of the peripheral zone remain the gold
standard of PCa detection. Contrast-enhanced targeted biopsy showed to significantly increase cancer
and per core biopsy rate compared with SB. Furthermore contrast-enhanced targeted biopsy detected a
significantly higher mean Gleason score. In the future targeted bubbles may further improve PCa
detection and bubbles loaded with drugs will offer new therapeutic options. However, these methods,
are still not used in standard clinical practice.
Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, et al. Cancer statistics, 2008. CA Cancer J Clin
Pallwein L, Mitterberger M, Pelzer A, Bartsch G, Strasser H, Pinggera GM, et al. Ultrasound of prostate
cancer: recent advances. Eur Radiol 2008;18(4):707-15.
Heidenreich A, Aus G, Bolla M, Joniau S, Matveev VB, Schmid HP, et al. EAU guidelines on prostate
cancer. Eur Urol 2008;53(1):68-80.
Tang J, Li S, Li J, Luo Y, Xu J, Zhang Y, et al. Correlation between prostate cancer grade and vascularity
on color doppler imaging: preliminary findings. J Clin Ultrasound 2003;31(2):61-8.
Frauscher F, Klauser A, Volgger H, Halpern EJ, Pallwein L, Steiner H, et al. Comparison of contrast
enhanced color Doppler targeted biopsy with conventional systematic biopsy: impact on prostate cancer
detection. J Urol 2002;167(4):1648-52.
Mitterberger M, Pinggera GM, Horninger W, Bartsch G, Strasser H, Schafer G, et al. Comparison of
contrast enhanced color Doppler targeted biopsy to conventional systematic biopsy: impact on Gleason
score. J Urol 2007;178(2):464-8; discussion 468.
Mitterberger M, Horninger W, Pelzer A, Strasser H, Bartsch G, Moser P, et al. A prospective randomized
trial comparing contrast-enhanced targeted versus systematic ultrasound guided biopsies: impact on
prostate cancer detection. Prostate 2007;67(14):1537-42.
- 36 -
Ultrasound contrast agent diffusion imaging for localization
of prostate cancer
M. P. J. Kuenen1, M. Mischi1, H. Wijkstra2, A. J. M. Hendrikx3 and H. H. M. Korsten1, 4
Eindhoven University of Technology, Department of Electrical Engineering, The Netherlands
Academic Medical Center, Department of Urology, Amsterdam, The Netherlands
Catharina Hospital, Department of Urology, Eindhoven, The Netherlands
Catharina Hospital, Department of Anesthesiology and Intensive Care, Eindhoven, The Netherlands
Prostate cancer is the most common form of cancer in Western men [1, 2]. Accurate quantitative
imaging methods may possibly provide an early detection and enable an efficient use of focal
treatments. However, no such imaging method is yet available. As a consequence, the diagnosis is
currently based on 6 to 12 geometrically distributed biopsies. This invasive procedure is often repeated
several times to achieve sufficient reliability.
Cancer growth and aggressiveness are related to angiogenesis, i.e., to the formation of a dense network
of microvessels [3]. Recent technical developments permit dynamic contrast-enhanced ultrasound
imaging of the prostate circulation at a high resolution [4]. This involves the intravenous injection of a
small ultrasound contrast agent bolus, followed by the ultrasound measurement of indicator dilution
curves (IDCs), representing the bolus first pass through the prostate circulation [5, 6]. Although
promising, quantification of IDC patterns is necessary for a clinical application.
Aimed at the quantification of angiogenesis, several methods have proposed the estimation of perfusion
from IDC parameters, based on timing or intensity features [7, 8]. However, timing features depend on
the entire bolus history, and don’t represent the local hemodynamic characteristics at the measurement
site; intensity features are affected by nonlinear attenuation [9]. Furthermore, the effects of
angiogenesis on perfusion are complex, inconsistent and contradictory [10].
- 37 -
Figure 3 Contrast-enhanced ultrasound image of the
prostate, showing both the contrast-enhanced (left) and
fundamental (right) imaging modes.
In this study we propose an alternative method, which quantifies the local, intravascular diffusion of
ultrasound contrast agents. We expect diffusion to correlate better than perfusion to changes in the
microvascular architecture that are caused by angiogenesis.
Materials and methods
Data acquisition was performed at the AMC, Amsterdam. A 2.4 mL SonoVue® (Bracco, Milan, Italy)
bolus was injected intravenously. Transrectal ultrasound power modulation imaging (frequency 3.5
MHz, mechanical index 0.06) was performed using an iU22 scanner (Philips Healthcare, Bothell, USA)
equipped with a C8-4v transducer.
An IDC is measured at every pixel of the resulting B-mode video. The IDCs are modeled by the Local
Density Random Walk model, which is a solution of the convective diffusion equation [11]. We have
refined the IDC formalization, such that it permits the estimation of a diffusion-related parameter that
can be interpreted locally, i.e., independently of the entire vascular path. In particular, this parameter,
related to local diffusion, is reflected in the IDC skewness.
We present a fast fitting algorithm to estimate the IDC parameters at every video pixel, producing a
parametric image (see Figure 2). The algorithm, which relies on the linear relation between measured
acoustic intensity and contrast agent concentration, compensates for the dynamic-range compression
Gray level
Gray level
applied by the scanner. Dedicated spatio-temporal filtering is applied to improve the fitting robustness.
Time [s]
Time [s]
Figure 4 Diffusion parametric image with typical IDC
patterns encountered in healthy (top right) and cancerous
(bottom right) tissue.
- 38 -
A preliminary validation was conducted based on two patients. The diffusion parametric images were
compared to histology data, obtained after radical prostatectomy at the AMC in Amsterdam.
On a pixel basis, there was a good agreement between the diffusion parametric images and the
histology assessment. Regions of interest of at least 1000 pixels were considered. Sensitivity and
specificity were 78% and 92%, respectively. The ROC curve area was 0.91, which was superior to that
obtained by testing all the other IDC parameters reported in the literature [7, 8].
Quantification of local diffusion of ultrasound contrast agents is a promising method for the localization
of prostate cancer. A more extensive validation, e.g., by a comparison with other techniques and with a
higher number of patients, is however necessary to assess the clinical reliability of the method.
[1] Jemal, A. et al, Cancer statistics, 2008, CA Cancer J. Clin., 58(2), 71-96, 2008.
[2] Ferlay, J. et al, Estimates of the cancer incidence and mortality in Europe in 2006, Ann. Oncol., 18, 581-592,
[3] Weidner, N. et al, Tumor angiogenesis correlates with metastasis in invasive prostate carcinoma. Am. J.
Pathology, 143(2), 401-409, 1993.
[4] De Jong, N. et al, Detection procedures of ultrasound contrast agents, Ultrasonics, 38, 87-92, 2000.
[5] Wink, M. H. et al, Transrectal contrast enhanced ultrasound for diagnosis of prostate cancer, World J. Urol.,
25, 367-373, 2007.
[6] Pallwein, L. et al, Ultrasound of prostate cancer: recent advances, Eur. Radiol., 18, 707-715, 2008.
[7] Eckersley, R. J. et al., Quantitative microbubble enhanced transrectal ultrasound as a tool for monitoring
hormonal treatment of prostate carcinoma, Prostate, 51, 256-267, 2002.
[8] Elie, N. et al, Methodology for quantifying interactions between perfusion evaluated by DCE-US and
hypoxia throughout tumor growth, Ultrasound in Med. & Biol., 33(4), 549-560, 2007.
[9] Tang, M.-X. and R. J. Eckersley, Nonlinear propagation of ultrasound through microbubble contrast agents
and implications for imaging, IEEE Trans. Ultrason. Ferroelect. Freq. Contr., 53(12), 2406-2415, 2006.
[10] Delorme, S. and M. V. Knopp, Non-invasive vascular imaging: assessing tumour vascularity, Eur. Radiol.,
8, 517-527, 1998.
[11] Sheppard, C. W., Basic principles of the tracer method, New York: John Wiley and Sons, 1962.
- 39 -
Peter Frinking, Laurent Mercier, Nicolas Rognin, Marcel Arditi, François Tranquart and
Michel Schneider
Bracco Research S.A. – Geneva / Switzerland
Lesion detection and characterization for cancer diagnosis in e.g. liver, breast or prostate has become an
important field of application in contrast-enhanced ultrasound imaging. In prostate, for example,
systematic biopsy, currently still the “gold standard” for prostate cancer diagnosis, misses
approximately 30% of cancers [1]. Even new biopsy strategies, such as increasing the number of cores
taken during a biopsy examination, have low success rates [2]. With conventional (i.e. unenhanced)
ultrasound imaging, the detection of prostate cancer, aimed at identifying hypoechoic areas in the
peripheral zone, is unreliable [3]. However, studies of targeted biopsy approaches using contrastenhanced ultrasound guidance have shown that the number of positive biopsy cores increases, and that
the total number of cores normally taken with systematic biopsy approaches can be reduced [4].
Moreover, with the help of new perfusion quantification analysis methods, contrast-enhanced
ultrasound may soon provide an alternative to systematic biopsy as the first choice for prostate cancer
diagnosis. This could result in a major and welcome reduction in patient discomfort and morbidity, and
could dramatically decrease associated costs.
In contrast-enhanced ultrasound imaging, lesion detection is typically based on differences in contrast
enhancement (hypo- or hyper-enhancement) and perfusion kinetics compared to normal tissue [5][6].
Perfusion kinetics can be measured and quantified by recording so-called time-intensity curves (TIC),
which represent the echo-power as a function of time and, consequently, relate to the time evolution of
the local instantaneous contrast agent concentration after, for example, a bolus injection [7]. These TIC
are normally analyzed after the examinations using dedicated off-line post-processing quantification
software. By off-line analysis using best-fit optimization approaches, perfusion parameters, such as
Intensity/Enhancement (PI), Wash-in Rate (WiR), Wash-out Rate (WoR), etc., are extracted from
sophisticated mathematical models describing the bolus kinetics of the contrast agent [8]. These
perfusion parameters are typically presented as single values obtained from analyzing a pre-defined
region-of-interest (ROI), or they can be presented as static parametric images showing the spatial
variation of values of any parameter of interest, on a pixel-by-pixel basis [9].
- 40 -
For lesion characterization, benign lesions can be differentiated from malignant lesions based on
differences in their vascular properties, such as microvascular density and/or structure. Thus, lesions
can be characterized by imaging and analyzing the finest details of the microvascular network,
preferably on full resolution images. Capturing the complete microvascular structure of a lesion under
investigation is often challenging in contrast-enhanced ultrasound imaging because the instantaneous
local agent concentration can be extremely low, even to the extent that single microbubbles are imaged
flowing in microvessels. This hinders the rendering of the complete microvascular structure and,
therefore, limits correct lesion characterization. The microvascular structure can, however, be imaged
with contrast-enhanced ultrasound using so-called maximum-hold or maximum intensity projection
(MIP) imaging approaches (such as MVI™, MFI™, CPS-capture™), especially in situations of low
instantaneous local contrast agent concentrations. In MIP imaging, the absolute maximum echo value is
preserved over time in each pixel. In this way, trajectories of individual bubbles flowing through
microvessels are ‘projected’, and the finest details of the microvascular network can thus be imaged.
However, at times beyond the initial ‘arterial’ wash-in phase, MIP images generally have become
‘diffuse’ due to perfusion of normal parenchyma tissue, and image information specific to the
microvascular structure of a lesion has a tendency to fade. This limits the usefulness of MIP imaging for
lesion characterization considerably. Another limitation of MIP imaging may be its high sensitivity to
motion resulting in blooming artifacts.
Real-time parametric imaging
In this work, a new method was developed which allows for improved contrast perfusion imaging, by
displaying parametric images of contrast-enhanced ultrasound sequences in real-time. The method is
based on a robust smoothing algorithm, combining a maximum- and minimum-hold filter, applied on
image data in real-time. The video data are linearized also in real-time (i.e. producing echo-power
signals proportional to local contrast agent concentration) to revert the effects of non-linear logcompression and color rendering. In this way, images of microvascular structures are displayed in realtime during the wash-in phase after a bolus injection of a contrast agent, whereas distinct perfusion
kinetics related to the wash-in phase (and/or wash-out phase) are accurately preserved and can be
exploited in a rigorous way for dynamically displaying parametric images (i.e. the parametric images
are created also in real-time). Because of the robustness of the algorithm, the new method can be
applied on full resolution data with a low signal-to-noise ratio without the need for spatial filtering.
Consequently, full resolution parametric images can be created without loss of information. Thus,
differences in contrast agent perfusion between normal tissue, benign lesions and malignant lesions can
be optimally exploited for improved lesion detection.
- 41 -
The method has been optimized for contrast-enhanced ultrasound examinations of the prostate and is
implemented in a software program called SonoProstateLive. Because of the symmetry of the prostate
gland and its zonal anatomy, lesion detection is typically based on comparing contrast perfusion
kinetics in contra-lateral regions. Moreover, contrast-enhanced image sequences of prostate
examinations are convenient for real-time processing purposes since the images are relatively stable and
motion artefacts are practically non-existent. In this work, lesion detection and characterization was
restricted to the peripheral zone (PZ) since 80% of prostate cancer is located in the PZ [10]. Figure 1
illustrates an example of the new method applied on an image sequence recorded during a prostate
examination after a 2.4 mL bolus injection of SonoVueÒ.
25 s
30 s
35 s
40 s
50 s
Figure 1. Prostate images obtained during real-time WiR parametric image processing at different time
instants: at 25 s (A), 30 s (B), 35 s (C), 40 s (D) and 50 s (E) after a bolus injection of SonoVueÒ.
The final WiR parametric image (E) is overlaid with 50% transparency on the B-mode image in F.
Figures 1A to 1E show the results at different time instants during real-time processing. During the
early part of the wash-in phase 25 s after injection (Figure 1A), the contrast agent appears in the highly
vascularized central zone (i.e. middle part) of the prostate, showing the typical symmetric enhancement
of this part of the prostate. The MIP character of the method at this stage of processing enhances
relatively big vessels of the vascular network already at this early part of contrast wash-in (see for
example the bright ring on the right side in Figure 1A). Also, an asymmetric enhancement pattern in the
right peripheral zone of the prostate (i.e. on the lower-left side in the MIP image in Figure 1A indicated
by the arrow), which is absent in the contra-lateral part of the prostate, appears and suggests the
presence of a suspicious region in this part of the prostate. During late wash-in of the agent at 30 s after
injection (Figure 1B), the suspicious region is well delineated, enhancing branches of its vascular
network, which is a clear indication of a malignancy. After the wash-out has started in the lesion and
- 42 -
normal surrounding tissue is perfused at 35 s after injection (Figure 1C), the method switches to
parametric imaging and starts to create parametric maps in real-time.
Figures 1D and 1E show examples of full-resolution parametric images (i.e. pixel-by-pixel with no
spatial filtering applied) of WiR at 40 and 50 s after injection, respectively. For each pixel in the image,
the WiR values are normalized to a reference value calculated globally, and are subsequently color
coded according to a predefined palette with red colors corresponding to large values and blue colors
corresponding to low values of the WiR. The suspicious region in the right PZ of the prostate can be
clearly identified against normal regions in the contralateral zone, by the relatively high density of high
WiR values, and remains conspicuous even during the (late) wash-out phase. Moreover, the high
resolution parametric images reveal details of the microvascular system, allowing improved detection
and may facilitate characterization. Functional information may be combined with anatomical
information by overlaying the final WiR parametric image of Figure 1E on the B-mode image. Figure
1F shows the final results, applying a 50% transparency for the WiR parametric image. In this way, it
can be easily recognized if a suspicious lesion is completely contained within the prostate gland or if it
is extending outside the gland. This kind of information may be important as it will condition the choice
of possible therapeutic strategies to follow. Note that also in the transition zone (TZ), regions with a
high density of high WiR values are observed, which is mainly due to the hyper vascular character of
TZ tissue. However, it is anticipated that for detecting prostate cancer (PCa) in PZ this will not be a
problem in practice, since in most cases PZ can be easily separated from TZ due to the zonal anatomy
of the prostate.
The method was tested in a clinical context during contrast-enhanced ultrasound examinations of four
patients scheduled for radical prostatectomy. SonoProstateLive was installed on a notebook computer,
operating under MS-Windows XP, which was connected to the video output of an ultrasound scanner
through a digital video frame grabber. This allowed to process the contrast sequences in real-time
during the examination. The resulting WiR parametric images were analyzed subjectively, and
suspicious regions were identified. Their locations were compared to data available from biopsy
histopathology reports, and in all four cases, the final WiR parametric images allowed correct
identification of PCa. Moreover, the method was validated in a qualitative way by retrospective off-line
analyses on image sequences of previously recorded contrast-enhanced ultrasound examinations.
Possible locations of PCa identified in the WiR parametric images generated by SonoProstateLive were
compared to histopathology data obtained after either biopsy or radical prostatectomy. The locations of
PCa given by SonoProstateLive corresponded in all cases with the histopathology data.
- 43 -
Figure 2 shows an example of the qualitative validation with the overlaid WiR parametric image of
Figure 1F on the left-hand side and the corresponding histology section on the right-hand side. The
suspicious region identified by a relatively high density of high WiR values in the right PZ of the
parametric image (red arrow), correctly corresponded with PCa as outlined by the pathologist in blue in
the histology section. An adenoma was also present in the left TZ of the same prostate, as is indicated
by the green arrow in the histology section. The same location in the WiR parametric image (green
arrow) corresponded to a region with a non perfused internal part (i.e. with WiR values close to zero)
and a hyper vascular peripheral part with a high density of high WiR values. This might be a typical
characteristic of adenoma in prostate and could be used for lesion characterization, but this is subject
for future studies.
WiR parametric image
O. Rouvière, Hôpital E. Herriot , Lyon, France
Figure 2. WiR parametric image (left) and corresponding histology coupe (right). A suspicious region identified in the
WiR parametric image in the right PZ (red arrow) corresponds with PCa outlined by the pathologist in blue in
the histology section. Adenoma was also detected in the left TZ of the same prostate (green arrow).
Statistical analysis.
Parametric images of WiR may facilitate the identification of possible locations of a pathological
condition. Indeed, the example illustrated in Figure 2 showed that a region with a relatively high density
of high WiR values in the right PZ corresponded to the location of PCa, whereas normal tissue
corresponded to regions of low WiR values. Therefore, distributions of WiR values were statistically
analyzed based on their histograms calculated in ROI placed in the parametric images (a histogram of
WiR values calculated in a ROI of a parametric image reflects perfusion information at the pixel level).
Figure 3 illustrates the principle on the WiR parametric image of Figure 1. A ROI was drawn in the
parametric image around the right PZ with PCa, and a histogram of all WiR values within this ROI was
calculated. The graph on the right-hand side of Figure 3 shows the resulting histogram (blue bars),
where WiR values are plotted on the x-axis and the corresponding normalized counts are plotted on the
y-axis. The counts were normalized to the total number of counts in the ROI to make the distribution
independent of the ROI size.
- 44 -
Next, the original histogram was smoothed (red curve shown on the right-hand side in Figure 3) with a
lognormal probability density function of the form:
F ( x) =
[ln( x ) -m ]2
x s 2p
where m and s are the mean and standard deviation of the natural logarithm of x, respectively (x
corresponds to the WiR values). Values for m and s are determined by a best-fit analysis between F(x)
and the original histogram. Smoothing the original histograms allows improved comparison between
histograms obtained from different regions in the prostate. For example, Figure 4 on the left shows in
red the smoothed histogram of Figure 3 calculated in the right PZ with PCa, and in green the one
calculated in the contra-lateral region representing normal tissue, i.e. in the left PZ. The histogram
curve corresponding to the right PZ with PCa is very different in shape compared to the one from
normal tissue in the left PZ; its peak value is lower, its peak position is shifted to the right, i.e. to higher
WiR values, and its peak is wider, i.e. reflecting a larger variation of WiR values.
WiR parametric image
WiR histogram (PZ-right)
PZ right
Figure 3. WiR parametric image (left) and corresponding histogram of WiR calculated in the right PZ shown in the
parametric image (right). The original histogram (blue bar plot) is smoothed with a lognormal distribution
function (red curve) obtained from a best-fit optimization procedure.
Shape differences between the histogram curves, corresponding to different lesions or types of tissue,
may be exploited by extracting parameters from the lognormal distribution function, obtained after the
best-fit optimization with the WiR histograms. Examples of such parameters are: the Mean (center of
gravity of the histogram curve), Mode (value at the peak, i.e. the most frequently occurring value in the
histogram), Median (middle value, i.e. the value such that an equal number of samples are less than and
greater than said value), Sigma (standard deviation, i.e. the variability or dispersion around the Mean of
the histogram curve) and Skewness (asymmetry of the histogram curve). These parameters can be
calculated from the best-fit parameters m and s by:
- 45 -
Mean = e
, Mode = em- s , Median = em , Sigma = e s
+ 2m
(e s - 1) and Skewness = e s - 1 (2 + e s )
Here, we used a combination of the Mode and Sigma parameters to compare histogram curves
corresponding to different lesions or types of tissue located in the PZ. For both histogram curves shown
on the left-hand side of Figure 4, the Mode and Sigma parameters were calculated. Next, a 2dimensional (2D) map of Mode and Sigma was generated in which the Mode was plotted on the x-axis
and Sigma on the y-axis, and the results are shown on the right-hand side in Figure 4; the data point
corresponding to normal tissue in PZ is plotted in the lower-left region of the 2D map, whereas the one
corresponding to PCa in PZ is plotted in an upper right region relative to normal tissue. This example
suggests that a 2D representation of shape parameters obtained from histogram curves of a WiR
parametric image may be used to differentiate between PZ tissue with and without cancer.
PZ left (normal)
2-D parametric plot
WiR histogram (PZ)
Cancer (PZ right)
PZ right (cancer)
Normal (PZ left)
Figure 4. Fitted lognormal histogram curves (left) calculated in right PZ with PCa (red curve) and left PZ
containing only normal tissue (green curve). Corresponding Mode and Sigma were calculated from
the best-fit parameters m and s, and were plotted in a 2D map (right). Data points relating to normal
tissue or PCa in PZ are plotted in very distinct regions in the 2D parametric plot.
To validate this approach, 23 DICOM image sequences of different patients were studied
retrospectively off-line. The image sequences were acquired during contrast-enhanced ultrasound
examinations with different ultrasound systems (18 with the Philips iU22, 4 with the Siemens Sequoia,
and 1 with the Toshiba Aplio) by 5 different users. Histogram curves were calculated in 62 ROI located
in PZ containing different lesions or types of tissue. For each histogram curve, the Mode and Sigma
parameters were calculated and the 2D map of Mode and Sigma was generated. Histopathology data,
obtained after biopsy examinations or radical prostatectomy, was available for 26 ROI in 8 patients and
confirmed 14 cases of PCa, 2 cases of Prostatitis and 10 cases of normal tissue; no data was available
for the remaining 36 ROI. Figure 5 shows the 2D map of Mode and Sigma calculated in all 62 ROI.
Data points with known histopathology were colorized according to the type of lesion or tissue, viz.
- 46 -
green for normal tissue, red for PCa and orange for Prostatitis in the PZ. Data from PCa and normal
tissue in PZ are located in distinct regions in the 2D map, as was described above; normal tissue data
appears to be relatively uniform distributed in the lower-left region, whereas PCa data is more dispersed
and located in an upper-right region relative to normal tissue data. The dispersion observed for PCa data
may be explained by a high heterogeneity in tumor development, as would be expected for different
patients. Moreover, based on the results shown in Figure 5, it may be possible to differentiate Prostatitis
(benign tissue) from PCa in PZ, but this should be confirmed by including more data.
Norm al
Figure 5. 2D map of Mode and Sigma calculated in 62 ROI. Data points with known histopathology were colorized
according to the type of lesion or tissue (see color legend).
The results shown in Figure 5 confirm the suggestion made above that the distinct regions in the 2D
map of Mode and Sigma correspond to the different lesions or tissue located in the PZ, and thus that this
method may be used for improved lesion characterization in PZ of the prostate. It is furthermore
interesting to note that, especially for normal tissue, all results are consistent even though the data were
acquired with different ultrasound systems and by different users, each with their own preferred
settings. This suggests that the method is very robust and could reduce operator-dependent variability.
In summary, real-time WiR parametric imaging, as implemented in SonoProstateLive, is a new imaging
modality which may allow improved lesion detection in PZ during contrast-enhanced ultrasound
examinations of the prostate. Parametric images of WiR are generated during the examinations,
mapping the spatial distributions of WiR values in the prostate as soon as 50 s after agent injection, and
could be used for targeted biopsy guidance. Moreover, perfusion kinetics information is available to the
- 47 -
examiner even after the wash-out phase of the agent, whereas in normal contrast examinations the
effective observation time for lesion detection is limited to 20 to 30 s only. Since multiple foci occur in
more than 85% of the cases of PCa [11], SonoProstateLive might increase chances of detecting small
lesions which would have been missed during a conventional contrast examination.
The results from SonoProstateLive can be further analyzed for characterization purposes. A 2D map of
Mode and Sigma of the statistical distribution of WiR in a ROI could facilitate lesion characterization in
PZ of the prostate by contrast-enhanced ultrasound. Consequently, it could lower false-positive findings
in prostate cancer detection and thus would decrease overdiagnosis and overtreatment of patients with
prostate cancer. However, the preliminary results of this work need to be confirmed by a prospective
clinical validation study. Another interesting topic would be to see if SonoProstateLive in combination
with the 2D map of Mode and Sigma could aid in determining the effect of a therapeutic treatment (e.g.
HIFU, brachy- or cryo-therapy), by assessing tumor response to treatment, and could identify nonresponders at an early stage during therapy. Finally, the possibility of detecting cancer in highly
vascular regions, such as in the TZ, should also be investigated.
Image sequences were kindly provided by Dr. H. Wijkstra (AMC, Amsterdam, The Netherlands), Prof. O.
Rouvière (Hôpital E. Herriot, Lyon, France), Dr. F. Frauscher (University Hospital Innsbruck, Austria), Prof. T
Fischer (Charité, University of Berlin, Germany) and Dr. Li Feng-Hua (Renji Hospital, Shanghai, China). Dr.
Wijkstra is also acknowledged for his valuable input and for allowing the opportunity for the live clinical test.
M. Norberg et al., “The sextant protocol for ultrasound-guided core biopsies of the prostate underestimates the
presence of cancer,” Urology, vol. 50, pp. 562-566, 1997.
J.S. Jones et al., “Saturation technique does not improve cancer detection as an initial prostate biopsy
strategy,” J. Urol., vol. 175(2), pp.485-488, 2006.
M. Moradi et al., “Computer-aided diagnoses of prostate cancert with emphasis on ultrasound-based
approaches: A review,” Ultras. Med. Biol., vol. 33(7), pp. 1010-1028, 2007.
M. Mitterberger et al., “A prospective randomized trial comparing contrast-mhanced targeted versus
systematic ultrasound guided biopsies: Impact on prostate cancer detection,” The Prostate, vol. 67, pp.
1537-1542, 2007.
F. Frauscher et al., “Ultraschallkontrastmittel un prostatakarzinom,” Radiologe, vol. 45, pp. 544-551,
A.R. Padhani et al., “Angiogenesis imaging in the management of prostate cancer,” Nature Clin. Pract.
Urology, vol. 2(12), pp.596-607, 2005.
N. Elie et al., “Methodology for quantifying interactions between perfusion evaluated by DCE-US and
hypoxia throughout tumor growth,” Ultras. Med. Biol., vol. 33(4), pp. 549-560, 2007.
M. Averkiou et al., “Quantification of tumor microvascularity with respiratory gated contrast enhanced
ultrasound for monitoring therapy,” Ultras. Med. Biol., In Press.
X. Gu et al., “Parametric perfusion imaging based on low-cost ultrasound platform,” Ultras. Med. Biol.,
In Press.
J.E. McNeal et al., “Zonal distribution of prostate adenocarcinoma. Correlation with histologic pattern and
direction of spread,” Am. J. Surg. Path., vol. 12(12), pp. 897-906, 1988.
D.P. Byar and F.K. Mostofi, “Carcinoma of the prostate: prognostic evaluation of certain pathological
features in 208 radical prostatectomies. Examined by a the step-section technique,” Cancer, vol. 30(1), pp.
5-13, 1972.
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Sponsored by GE Healthcare
Thursday JANUARY 21
Oceanium, Blijdorp Zoo
Blijdorplaan 8, Rotterdam
Dinner buffet: 7.30- 10.15pm
Coaches will be leaving from Hilton at 6.30pm and will be back
there around 10.30pm.
- 49 -
Development of a cannulated vessel model for
simultaneous ultrasound exposure and microscope imaging
Anna Tokarczyk, Ian Rivens, Gail ter Haar
Joint Department of Physics, The Institute of Cancer Research: Royal Marsden NHS Foundation Trust,
Sutton, Surrey, SM2 5PT, UK
Ultrasound microbubble contrast agents (UCAs) are now commonly used in diagnostic
ultrasound, and their use as therapeutic agents for cancer treatments is under active
consideration. The intention of this study is to investigate the effects of ultrasound (US)
exposure of UCAs on the blood vessels through which they flow, in order to assess potential
hazard, and also to investigate beneficial therapeutic effect.
An experimental model which uses an isolated, cannulated blood vessel (~400 µm diameter)
has been developed. This allows microscopic visualisation of vessel behaviour and damage
during therapeutic ultrasound exposures in the presence of contrast agent, and assessment of
changes in endothelial and smooth muscle cells.
Continuous 5 s exposures of 1.7 MHz High Intensity Focused Ultrasound have been used.
Vessel wall damage and leakage of intravascular buffer have been observed, predominantly in
the presence of Sonovue and at a peak negative pressure of 1.36 MPa.
The observed lack of vascular constriction and expansion in response to Phenylephrine and
Acetylcholine indicates smooth muscle and endothelial cell damage. This has been confirmed
by haematoxylin and eosin staining which revealed the changes in a blood vessel wall
This vessel model will also be used to investigate the bio-effects induced by the exposure of
vessels to diagnostic US exposures in the presence of contrast agents.
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Assessment of coronary flow reserve, myocardial perfusion
and function in two cases of Takotsubo cardiomyopathy.
Insights into pathophysiological mechanisms
*Francesco Bartolomucci MD, Ph.D, *Giovanni Deluca MD, *Riccardo Ursi MD,
*Domenico Paulillo MD, §Alessandro Distante MD.
Department of Cardiology ASL BAT, § Departemnt of Cardiology – University of Pisa
Transient apical ballooning syndrome is a cardiac condition characterized by chest pain, transient ECG
and wall motion abnormalities, associated with minimal release of biochemical indexes of myocardial
necrosis, and with no evidence of obstructive coronary artery disease. This syndrome that was first
described by Sato and colleagues and named by these authors “Takotsubo Cardiomyopathy. We report
three case of Takotsubo cardiomyopathy that recently came to or observation and underwent a series of
investigations, aimed at clarifying the potential mechanisms responsible for its occurrence.
A 2 old women with a history of hypertension presented to the emergency room of our hospital
complaining of acute-onset, constrictive retrosternal chest pain, that lasted approximately 30 minutes.
The day before symptoms’ onset, the patients have suffered severe emotional stress. The ECG showed
(Fig.1), typical ischemic-like, 3mm ST segment elevation across the chest leads; the echocardiogram
documented normal cavity dimensions, severe LV systolic dysfunction (EF 35%) with and apical and
mid-ventricular akinesis and hyperkinesis of the basal segments. The patients were as immediately
brought to the catheterisation laboratory to undergo selective coronary arteriography that ruled out
significant coronary artery disease. Left ventriculography confirmed impairment of systolic function
with typical apical ballooning.(fig.1) Troponin levels peaked approximately 10 hours after symptoms’
onset to a value of 2.6 mg/L and completely normalized within 36 hours.
Twenty-four hours after admission, the patients underwent assessment of left anterior descending
(LAD) coronary flow reserve (CFR) by transthoracic color-doppler echocardiography. CFR was
measured at the distal end of the LAD, during intravenous adenosine infusion (0.14mg/Kg/min over 2
min), and found to be mildly depressed ( x 2.1 resting flow velocity).
Four hours after completion of the LAD flow velocity study, regional myocardial perfusion was
assessed, in real-time, by contrast echocardiography by i.v. injection of Sono-View, low mechanical
index microbubbles. (fig.2) Perfusion was essentially preserved in most dysfunctional segments, with
the exception of a limited subendocardial portion of the left ventricular apex in a case and in the other
case there is a delay replenishment of the left ventricular apex. During the same session, the patients
underwent a viability study by low-dose dobutamine echocardiography (LDDE), with a starting dose of
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5m/Kg/min for 5 minutes, followed by a 15m/Kg/min dose for 10 more minutes. No apparent
improvement in regional systolic wall motion was observed.
During hospitalisation, the patients remained asymptomatic, with no clinical sign of heart failure. The
echocardiogram showed normal global and regional LV function. Hyperaemic response to adenosine
was also substantially improved (33% improvement) (fig. 3), relative to the initial study. Finally,
contrast echocardiography demonstrated complete normalisation of myocardial perfusion in the affected
Our observations and those reported in the literature, support the idea that the fundamental process
underlying the development of this condition is represented by neurogenic myocardial stunning, caused
by catecholamine-mediated direct myocardial injury. Although microvascular function and myocardial
perfusion can be somewhat impaired in some case, these alterations are probably epiphenomena of the
latter mechanism, and likely to play a minor causative role, rather than being primary
pathophysiological determinants of Takotsubo cardiomyopathy.
Address for Correspondence
Francesco Bartolomucci MD, Ph.D, FESC
U.O.C. di Cardiologia e UTIC, Ospedale “L. Bonomo”
Viale Istria 1
70031 Andria
tel. + 39.0883.541759
Fax + 39.0883.299225
E-mail:[email protected]
Fig.1. Left ventricular angiography (end-systolic frame) obtained on admission
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Fig.2 Real-time evaluation of myocardial perfusion by contrast echocardiography. Mild subendocardial underperfusion of the
left ventricular apex is observed (red arrows). Myocardial perfusion completely normalized at follow-up (see text).
Fig. 3 Non invasive assessment of LAD coronary blood flow velocity and flow reserve one month after admission. Coronary
flow reserve has completely normalized (x 3 resting flow). See text
- 53 -
Blood volume and ejection fraction measurements using
Drs. I.H.F. Herold1, Ir. M.P.J. Kuenen2, Dr. Ir. M.Mischi2, Prof. Dr. H.H.M. Korsten1,2
1. Catharina Hospital Eindhoven, Department of Anesthesiology and Intensive Care
2. Eindhoven University of Technology, Department of Electrical Engineering
Maintenance of adequate circulating blood volume is essential to preserve sufficient cardiac output (CO)
and organ perfusion. A safe and minimally invasive technique to quantify the circulating blood volume
during surgery and Intensive-Care is therefore required. Mischi et al. showed that blood volumes can be
assessed using Contrast Enhanced Ultrasound (CEUS) [1-3]. This assessment involves the estimation of
the CO and the differences in Mean Transit Time (MTT) of Ultrasound Contrast Agent (UCA) Indicator
Dilution Curves (IDCs) measured in different regions of interest (ROI) in the cardiac chambers. These
measurements provide an accurate and minimally invasive estimation of the main blood volumes. The
Pulmonary Blood Volume is analyzed by two first-pass IDCs measured in the right ventricle and left
atrium ROI. The Total Circulating Blood Volume is analyzed by a first- and second-pass IDC in the same
ROI, and the Systemic Circulating Blood Volume is analyzed by a first-pass IDC in the left ventricle ROI
and a second-pass IDC in the right atrium ROI.
The golden standard for CO measurements is cold thermodilution, based on the injection of a cold
saline bolus. A simultaneous measurement of both CO and UCA-IDCs can be performed by the
intravenous injection of a cold (4°C) bolus of an UCA dispersion in saline. In our study, SonoVue®
(Bracco, Italy) UCA was adopted.
The quantitative analysis of UCA IDCs involves the establishment of the relationship between UCA
concentration and acoustic backscatter. This procedure is referred to as calibration. Given the contradictory
results that are reported on the reflective properties of cold bubbles in the literature [6], we repeated a
calibration study prior to our measurements in patients. The acoustic response of cold SonoVue® was
determined using an iE 33 ultrasound scanner (Philips Healthcare, the Netherlands) equipped with a
transesophageal X7-2t 3D transducer. A transesophageal transducer was chosen because of its increasing
utilization in surgery and intensive-care as well as its position, very close to the left atrium. The choice for
a 3D transducer was made to permit validation by full-volume (3D) measurements of the algorithm
proposed by Mischi et al. [3-5] for IDC-based ejection fraction measurements.
Similarly to the measurements at room temperature (RT), also in the lower concentration range, up to
1,5 mg/L (Fig. 1), the acoustic backscatter of cold SonoVue® is linearly related to the UCA concentration.
Moreover, the acoustic backscatter of SonoVue® at 4°C is surprisingly similar to that at RT in the lower
range (fig.1). The life time of bubbles at 4°C is 30% longer than at RT, facilitating the detection of the
UCA recirculation and, therefore, the assessment of Total and Systemic Circulating Blood Volumes.
- 54 -
The dose for the intravenous injection in patients can be estimated on the base of the calibration results
in order to keep the measurement in the linear calibration range. However, a larger dose must sometimes
be injected to improve the detection of recirculation IDCs, resulting in first-pass IDCs that are distorted by
ultrasound attenuation. A dedicated algorithm has therefore been developed to correct for the IDC
distortion based on the calibration results and proper dilution modeling.
We believe that this novel, minimally invasive, non-nuclear method for measuring Pulmonary Blood
Volume as well as Total and Systemic Circulating Blood Volumes may be an asset in clinical research and
Acoustic Intensity AU
Calibration SonoVue® at Room temperature
and < 4˚C
Cold SonoVue
Room temp SonoVue
Concentration SonoVue® mg/L
Figure 1
M. Mischi, A.A.C.M. Kalker, H.H.M. Korsten, “Contrast Echocardiography for Pulmonary Blood
Volume Quantification,” IEEE Transactions on Ultrasonics, Ferroelectrics, and Frequency Control, vol.
51, no. 9 , pp. 1137-1147, Sep. 2004.
H.H.M. Korsten, M. Mischi, R.J.E. Grouls, A. Jansen, J.-M. van Dantzig, and K. Peels, “Quantification
in Echocardiography,” Seminars in Cardiothoracic and Vascular Anesthesia, vol. 10, no. 1, pp. 57-62,
M. Mischi, A.H.M. Jansen, and H.H.M. Korsten, “Identification of cardiovascular dilution systems by
contrast ultrasound,” Ultrasound in Med. & Biol., vol. 33, no. 3, pp. 439-451, 2007.
M. Mischi, A.H.M. Jansen, A.A.C.M. Kalker, H.H.M. Korsten, “Identification of Ultrasound-ContrastAgent Dilution Systems for Ejection Fraction Measurements,” IEEE Transactions on Ultrasonics,
Ferroelectrics, and Frequency Control, vol. 52, no. 3, pp. 410-420, 2005.
A.H.M. Jansen, M. Mischi, F. Bracke, J.-M. van Dantzig, K. Peels, N. van Hemel, H.H.M. Korsten,
“Novel Ultrasound-Contrast-Agent Dilution Method for Assessment of Ventricular Ejection Fraction,”
European Journal of Echocardiography, vol. 9, no. 4, pp. 489-493, 2008.
V. Mor-Avi, K.A. Robinson, S.G. Schroff, R.M. Lang, “Effects of temperature on Albunex and FS069
echocardiographic contrast agents: in vitro investigation usting ultrasonic irradiation,” Echocardiography,
vol 14, no , pp39-49, 1997
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Ultrasound and microbubble mediated gene therapy:
effectiveness of siRNA versus plasmid DNA delivery
Bernadet.D.M. Meijering1,2, Robert H. Henning1, Lynda Juffermans3, Leo.E.Deelman1.
Department of Clinical Pharmacology, Groningen Institute for Drug Exploration (GUIDE),
University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
Interuniversity Cardiology Institute of The Netherlands, Utrecht, Netherlands, 3 Department of
Physiology, VU University Medical Center, Amsterdam, Netherlands.
Background: Ultrasound and microbubbles targeted delivery (UMTD) may become a
therapeutic tool in the treatment of vascular disease. Recently, we demonstrated that in UMTD,
small molecules enter the cell through transient pores while the entry of larger molecules is
dependent on endocytosis. We therefore now hypothesize that UMTD of siRNA is more
efficient in changing gene expression than UMTD of plasmids.
Methods: the efficiencies of UMTD of SiRNA and plasmid DNA in changing the expression of
the moderately expressed gene GAPDH was compared in cultured primary endothelial cells.
Results: UMTD of siRNA transfected 97.9±1.5% of all endothelial cells, with labeled siRNA
both in the nucleus and cytoplasm immediately and decreased GAPDH protein levels by 70%.
In contrast, following UMTD of GAPDH plasmid DNA, only 2.0 ± 0.7 % of cells expressed
the transgene, which failed to increase overall GAPDH protein levels. Importantly, labeled
plasmid DNA was delivered to 43.0 ± 4.2% of all cells and was detected in endosomes positive
for clathrin and caveolin immediately and 24 hours after UMTD.
Conclusion: UMTD of siRNA is more effective than UMDT of plasmid in modifying protein
levels of the moderately expressed gene GAPDH in cultured endothelial cells.
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Virus loaded microbubbles as a tool for targeted gene
Bart Geers1, Ine Lentacker1, Angelika Alonso3, Stephen Meairs3, Joseph Demeester1,
Stefaan C. De Smedt1, Niek N. Sanders2
Laboratory of General Biochemistry and Physical Pharmacy; Faculty of Pharmaceutical sciences;
Ghent University; Harelbekestraat 72 9000 Gent, Belgium
Laboratory of Veterinary Gene therapy; Faculty of Veterinary sciences; Ghent University; Heidestraat
19 9820 Merelbeke, Belgium
Univ. Klinikum Mannheim, Department of Neurology, Heidelberg University, D-68167 Mannheim,
Objectives: Adeno-associated virus is a promising gene therapy vector because of its high transfection
efficiency. However, the use of AAVs in humans is limited by their high toxicity and their risk of
infecting non-target cells. To obtain a safe viral vector, the immunogenic capsid of the AAV should be
shielded from the immune system and the vector should be targeted to specific tissues. The objective of
this study is to couple PEGylated AAVs with avidin-biotin chemistry to lipid microbubbles in order to
obtain an ultrasound targeted release and transfection. This study will evaluate whether lipid
microbubbles release PEG-biotinylated AAVs upon ultrasound exposure and evaluate the transfection
efficiency of AAV loaded microbubbles in vitro. Hence AAV-loaded microbubbles may provide a
solution for ultrasound targeted viral gene delivery.
Methods: PEGylation of EGFP expressing AAV2 was done using NHS-PEG-Biotin (Iris Biotech
GmbH, Marktredwitz, Germany). Lipid microbubbles containing 85 mol% DPPC and 15 mol% of
DSPE-PEG-Biotin were prepared. In vitro experiments were performed on BLM melanoma cells in
Opticell plates and EGFP expression was measured with an FC500 Flow Cytometer. Ultrasound
experiments were performed using a Sonitron sonoporator with an ultrasound frequency of 1MHz,
2W/cm2 intensity and a 10% duty cycle.
Results: :
Zeta-potential measurements confirmed AAV pegylation using NHS chemistry. Flow
cytometry revealed that PEGylation of the AAV surface lowers their biological activity. We could
prove microbubble coupling of AAVs through NHS-PEG-Biotin chemistry, by confocal microscopy.
Flow cytometry analysis showed that melanoma cells can be infected by AAV loaded microbubbles and
ultrasound, provided that the AAVs are not too strongly PEGylated. Confocal microscopy uptake
studies however, showed an increased uptake after ultrasound treatment, possibly due to sonoporation
- 57 -
after bubble implosion. Although enhanced uptake was observed, an increased transfection rate is not
seen, possibly due to the fact sonoporation evades receptor mediated endocytosis.
Conclusion: This study shows that loading of softly-PEGylated AAV vectors to microbubbles by
avidin-biotin linkers is possible and ultrasound targeted delivery is possible using these constructs.
Targeted delivery of fully-PEGylated AAVs however is shown to be impossible, although more
adenoviruses are taken up ultrasound exposure. We believe that this uptake is due to sonoporation, a
mechanism which is believed to evade receptor mediated uptake. Adenoviral vectors are mostly
dependent of this mechanism, hereby limiting the functionality of ultrasound targeted drug delivery of
viral vectors.
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Enhancement of doxorubicin effect on cancer cell mortality
with ultrasound and microbubbles
J. Piron, A. Novell, K. Kaddur, A. Bouakaz
INSERM U930-CNRS ERL 3106, 37044 Tours cedex 1; Université François Rabelais, 37032 Tours,
Potential use of clinical ultrasound (US) in enhancing the anti-cancer drugs effects in the treatment of
cancers has been recently reported. Moreover US in combination with microbubbles have proven its
efficiency in improving molecule uptake into cells through sonoporation mechanism. In this work, we
want to verify that low intensity US and microbubbles could enhance anticancer-drug effect.
We evaluate the benefit of sonoporation in enhancing cell mortality using anti-cancer drug doxorubicin
with U87MG cells (human glioma cells) and MDA-MB231 cells (human breast adenocarcinoma).
Experiments were conducted in five groups: non treated, doxorubicin treated, US-microbubble treated,
doxorubicin + US, and doxorubicin + US-microbubble. Cells were exposed to 5µM doxorubicin and
sonicated at 1 MHz (with 40% duty cycle for 30s and acoustic pressures from 0.4 to 0.8 MPa). Twentyfour and 48h after treatment, cell mortality was evaluated by Trypan blue dye exclusion test. Four
experimental microbubble types were investigated: BR14, Sonovue, Vevo Micromarker® and
Polylactide Shelled microbubbles.
The results showed that for all microbubble types, a significant enhancement in doxorubicin effect was
achieved when it was co-administred with microbubbles in comparison to the drug alone. U87MG cell
viability in doxorubicin + US group was comparable to doxorubicin alone (57.4 ± 3.4 % versus 56.8 ±
3.7 % at 48h). When Vevo Micromarker® bubbles were co-administrated with doxorubicin, cell
viability percentage was only 21.0 ± 2.0 % at 48h respectively. Using Sonovue, Polylactide Shelled and
BR14 microbubbles, cell viabilities at 48h were respectively 39.6 ± 8.3 %, 40.6 ± 6.4 % and 32.7 ± 4.1
Thus, at 48h, ratios of doxorubicin + US-microbubble condition and doxorubicin alone are 1.08 and
1.31 for Sonovue and Polylactide Shelled microbubbles respectively. The highest ratios were obtained
with Vevo Micromarker® and BR14 microbubbles: 1.83 and 1.85 respectively.
With MDA-MB231 cells, the highest effect was obtained at 800 kPa Vevo Micromarker® bubbles.
Five more cells were died by doxorubicin treatment in presence of US and Vevo Micromarker®
bubbles. For others microbubble types, ratios were similar as those observed with U87MG cells.
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In order to provide insights into the differences in efficiency between the different microbubble types,
attenuation measurements were carried out before and after sonoporation. These acoustic behaviour
characterisation showed that at t=0, Vevo Micromarker® bubbles exhibit the lowest attenuation, and
that although a large part of the microbubbles are destroyed during the 30 seconds of insonation, only
Vevo Micromarker® bubbles were completely destroyed.
Our results demonstrate that low intensity US and microbubbles could enhance anti-cancer drug effect,
suggesting that this combination might be a useful tool for the cancers therapy.
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Targeted delivery of cell-based therapy for vascular repair
using acoustic radiation force
Catalin Toma, MD; Andrew Fisher, Jianjun Wang, PhD; Xucai Chen, PhD, Michelle,
Grata, BS, Huili Fu, PhD, William R. Wagner, PhD; Flordeliza S. Villanueva, MD.
Center for Ultrasound Molecular Imaging and Therapeutics, University of Pittsburgh and McGowan
Institute for Regenerative Medicine, Pittsburgh, PA
Background: Restoration of a functional endothelial barrier is a major requirement to preventing late
stent thrombosis; furthermore, intact endothelium protects against progression of atherosclerotic plaque.
To enhance endothelial repair in such settings, we are proposing a novel method for delivering cell
therapy to the vascular wall using ultrasound-generated acoustic radiation force (RF).
Methods: Fluorescently labeled mesenchymal stem cells (MSCs, zeta potential -23.2 mV) were
exposed in suspension to cationic lipid microbubbles (MB, zeta +55.2 mV) or negatively charged
control MB (zeta -10 mV), allowing for electrostatic MB:cell coating. MB:cell association was
quantified by flow cytometry based on the increased light scatter of the cell: microbubble complexes
and verified by microscopy. The concept was tested first in vitro in a PVC tube under flow conditions
(0.5Pa shear stress), with ultrasound (5 MHz, 1.2 MPa, 20% duty cycle) applied perpendicular to the
direction of flow. In vivo testing was then performed in rabbits following balloon injury to the
abdominal aorta, using an intravascular probe (1.7 MHz) to deliver RF to cell:MB complexes (3x105
fluorescently labeled rabbit MSCs) injected upstream of the injured segment.
Results: When RF was applied on MSCs passing through the PVC vessel phantom, arrest of 30±4 of
cells was observed when cationic MB were used (n=6), while no cell marginalization was present when
cells pre-mixed with negatively charged control MB were perfused. The effect was maximal when the
ratio of MSC:MB mixed together in suspension was 1:40, resulting in 88±5% of MSCs covered by MB,
with an average of 7±1 MB/cell (n=6). Acute in vivo histological results obtained at 20 minutes
following cell delivery identified 784±303 MSCs on the endoluminal surface of the RF-treated rabbit
aortic segment, while only 4±1 cells were found in the control area without RF (n=4, p<0.05).
Conclusions: Acoustic RF can be used to control and direct targeted endoluminal cellular paving in a
denuded arterial segment.
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Tracking of the Left Ventricular Borders in ContrastEnhanced Ultrasound Images
K.Y.E. Leung, M.D. Danilouchkine, M. van Stralen, N. de Jong, A.F.W. van der Steen, and
J.G. Bosch
Biomedical Engineering, Thoraxcenter, Erasmus MC, The Netherlands
Contrast agents are often used to enhance the visualization of the myocardium. For three-dimensional
(3D) imaging, studies have shown that contrast indeed allows better visual assessment of left
ventricular (LV) wall motion than noncontrast imaging1. To obtain a more quantitative measure of
cardiac motion, delineation of the LV border in contrast images is necessary. This delineation should
preferably be automated, to avoid tedious and subjective manual analysis.
In this study, we propose an automated method for 3D tracking of the endocardial borders. Standard
methods which suffice in noncontrast images may fail in contrast images, due to intricate swirling
patterns of the contrast. In particular, prior knowledge of the typical cardiac motion may be beneficial
for guiding the tracking. Here, we propose the use of statistical models to capture patient variability in
cardiac motion. The models represent the cardiac motion as frame-by-frame spatial transforms
(rotation, translation, scaling and shear) throughout the cardiac cycle, which are learned from manually
drawn borders in many patient image sequences. After generating these models, they are used to guide
an optical-flow method to track the end-diastolic LV borders throughout the cardiac cycle in a new
image sequence. Using the optical-flow equation, the motion between two image frames can be
estimated by taking into account the spatiotemporal gradients in image intensities2. The models are
integrated into the optical-flow equation to allow prior knowledge on cardiac motion to guide the
tracking. We compared this “motion-guided” tracking with the “basic” optical-flow method without
integrated models.
Evaluation is performed on 28 3D contrast-enhanced echocardiograms. An example of the tracking
performance is shown in Fig. 1. The motion-guided method gives better tracking results (volume error:
-1.5±10.1ml, ejection fraction error: 1.3±11.7%) than the basic method (volume error: 11.7±12.4ml,
ejection fraction error: 14.7±10.8%). In conclusion, tracking in contrast images is highly promising
using the proposed motion-guided method. By incorporated statistical prior knowledge, more consistent
tracking results can be achieved. This is an important step toward automated quantification of cardiac
function in contrast images.
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Cardiac cycle
Fig. 1. Example of 3D tracking of the LV borders. Four-chamber cross-section is shown here. Green denotes the
manually delineated ground truth, white the proposed “motion-guided” tracking, and magenta the basic tracking.
Notice the irregular borders found by the basic tracking, due to complicated swirling patterns of the contrast.
1. Nemes A, Geleijnse ML, Krenning BJ, Soliman OII, Anwar AM, Vletter WB, Ten Cate FJ. Usefulness of
ultrasound contrast agent to improve image quality during real-time three-dimensional stress
echocardiography. Am J Cardiol 2007; 99:275-278.
2. Lucas BD, Kanade T. An iterative image registration technique with an application to stereo vision. Proc
DARPA Image Understanding Workshop 1981:121-130.
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Microbubbles for Acousto-Optic Imaging Signal
Jack Honeysett1, Terence Leung1, Eleanor Stride2
Department of Medical Physics and Bioengineering, University College London, London, UK
Department of Mechanical Engineering, University College London, London, UK
Acousto-optic (AO) imaging is an attractive technique for biomedical applications on account
of its high spatial resolution. In tissue however, the AO signal is often very weak due to strong
optical scattering and this currently restricts the use of AO imaging to small tissue depths.
Various schemes have been proposed to overcome this including the use of intense acoustic
bursts, parallel detection using CCD cameras, and powerful long pulse laser illumination. The
aim of this study is to investigate the potential for using microbubble ultrasound contrast
agents to amplify the AO signals. The microbubble oscillations modify the AO signal in a
number of ways. Firstly, they generate varying optical scattering due to changes in its surface
area and internal refractive index. Secondly, they alter the pressure field around the bubble
which in turn generates refractive index changes in the surrounding medium. In this work
Monte Carlo (MC) simulations implemented on a graphical processing unit (Nvidia) are used
to investigate how these factors affect the optical phase of a photon as it propagates through a
turbid medium containing microbubbles. The scattering angle resulting from the collision
between a photon and a microbubble is determined by a Mie scattering based phase function.
The results show that the magnitude of the modulation depth of the AO signal is a function of
the microbubble optical and acoustic characteristics, their concentration in the medium, the
ultrasound frequency, the ultrasound intensity, as well as the optical absorption and scattering
characteristics of the medium. The implications of these findings and experimental results for
practical implementation will be discussed.
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Development of quantitative contrast ultrasound imaging
using the ovine ovarian model
Thomas DH1, Lampaskis M2, Silva N1, Strouthos C2, Averkiou M2, McNeilly AM3, Sboros
Department of Medical Physics and Medical Engineering, University of Edinburgh, Edinburgh, UK.
Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus.
MRC Human reproductive Sciences Unit, University of Edinburgh.
The ovary is a unique organ with cyclical changes in its microvasculature, good endocrinological
understanding and control, and has been used as a tumour model. It can thus be used as a model for
developing tools for the accurate imaging of microvascular changes, with relevance to a wide range of
microvascular disorders. The ability of parameters derived from time-intensity curves to provide
quantitative microvasculature measurements is examined here using the ovine corpus luteum (CL), a
highly vascular temporary endocrine structure within the ovary which is involved in production of
progesterone. Five ewes across various days of the cycle were investigated using contrast-enhanced
ultrasound with Sonovue®, in a pilot that assesses the usefulness of this model.
Each animal was opened under general anaesthesia, and the ovary was clamped in a fixed position
ensuring unaltered function and surrounded by ultrasound gel to allow an unhindered image of the CL
to be obtained with the L9-3 (Philips iU22) linear array probe. Contrast images were obtained using the
nonlinear pulsing scheme power modulation. Bolus and flash-infusion protocols were followed and the
captured uncompressed image data were analysed using first QLab v7.1 (Philips) image analysis
software and then using Matlab 2009a (Mathworks) for statistical interpretation. Parameters derived
from the time-intensity curves were calculated using the lognormal probability and the log normal
cumulative distributions for the bolus and infusion protocols respectively. Two different bolus doses
were used (1.2ml and 2.2ml) in order to asses the dose dependence of the time intensity parameters,
with each injection repeated 5 times (in each animal) to measure the reproducibility. The infusions
included 4.4ml of Sonovue® diluted in 10ml of saline at a rate of 4ml per min.
Mean values of standard error of 8% and 9% in the mean transit time (MTT) and wash in time (WIT)
were measured in the bolus injections in each sheep, showing high levels of reproducibility with no
significant dependence on the contrast dose. The peak intensity (Ipeak) values showed a strong
dependence on dose, both in amplitude and reproducibility; mean standard errors of 29% in the 1.2ml
injections versus 26% in the 2.2ml injections across the five sheep. Similar results were observed in the
area under the curve (AUC), with mean standard errors of 30% in the 1.2ml injections compared to
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17% in the 2.2ml injections. A destruction-replenishment protocol (six high amplitude frames of
0.5MI, repeated every 30seconds) showed increased variation in MTT and WIT in the contrast
replenishment curves, with standard errors of 29% and 42%. Variation of Ipeak is similar to the 2.2ml
bolus injections, with mean standard error of 19%.
The highly reproducible kinetic measurements with less than 10% variation in non-intensity related
parameters (WIT, MTT) show that the ovarian angiogenic function lends itself for in depth quantitative
non-invasive studies. Interestingly, amplitude related parameters (Ipeak, AUC) provided encouraging
results in this first attempt for quantification. Considering that a range of image settings, may affect
these more than WIT and MTT, these results encourage further future work with reference tracer
kinetics measurements from an independent vessel that may refine the measurement. In conclusion, the
ovine CL model may develop into a ‘golden standard’ for contrast ultrasound imaging of microvascular
measurements. The next steps include to fully exploit this model for the development of quantification
of small microvascular changes, which has implications, apart from the female reproductive system, for
a wide range of diseases such as ischemia, inflammation, cancer and their treatment monitoring.
- 66 -
Effect of Temperature on the Acoustic Characteristics and
Stability of Ultrasound Contrast Agents
Helen Mulvana1, Eleanor Stride2, Mengxing Tang3, Robert J Eckersley1
Imaging Sciences Department, Imperial College London, UK; 2 Mechanical Engineering Department,
University College London, UK; 3 Bioengineering Department, Imperial College London, UK.
Accurate characterisation of ultrasound contrast agents is important to support their use in quantitative
imaging and therapeutic applications. Laboratory investigations are frequently undertaken in a water
bath at room temperature, and the validity of these measurements with respect to microbubble
behaviour in vivo (37°C) is implicitly assumed.
In previous work (Mulvana et al., in press), we established that the bulk acoustic properties of a
suspension of the ultrasound contrast agent SonoVue (Bracco Research, Geneva) were influenced by
temperature. Increasing the suspending liquid temperature from 20 to 40°C led to an increase in
attenuation from 1.5 – 2.9 dB (P = 0.004) and a 2 dB (P = 0.05) increase in the amplitude of the
scattered signal from 2.3 – 2.9 kPa at an insonation pressure of 100 kPa. It was hypothesised that this
increase was due primarily to temperature mediated gas expansion and its resulting influence on the
size distribution of the bubble suspension. In addition, optical and acoustic experiments indicated that
bubbles at body temperature were less stable than those at 20°C.
This work further explores these observations through the high speed imaging of single bubbles.
A high speed camera (Cordin 550, Cordin, Salt Lake City, USA) was used to assess the influence of
increasing temperature from 20°C (RT) to 37°C (BT) on the dynamic behaviour of single SonoVue
bubbles excited at low (~50 kPa) and moderate (~100 kPa) acoustic pressures. Additionally, a series of
single bubbles were repeatedly excited at moderate acoustic pressures and their diameters prior to and
following each excitation were compared to assess bubble stability.
A dilute suspension of SonoVue was injected into a 200 μm diameter cellulose capillary tube held
within a tank of temperature controlled, filtered, de-ionised, gas-saturated, isotonic saline solution.
Single isolated bubbles were excited with a 12 cycle, 0.5 MHz, Gaussian windowed pulse using a 0.5
MHz single element focused transducer (f = 40 mm). During repeat insonation a 10 pulse burst with a
- 67 -
pulse repetition frequency of 100 Hz was used. The high speed camera was run at 2.5 MHz and a series
of 58 images obtained for each insonation. A fibre-optic hydrophone (Precision Acoustics, Dorset, UK)
used with a tapered sensor at 90° alignment was used to characterise the acoustic field. Images were
post-processed in Matlab to obtain time vs. diameter plots for each bubble.
At the lower pressure (Fig. 1a), maximum bubble excursion was not influenced by temperature,
indicating that under such conditions bubble behaviour is mainly determined by initial diameter. At
higher pressure (Fig. 1b), a slight increase was recorded in the maximum excursion at BT compared to
RT, as well as a slight change in the resonant frequency. Inspection of the images from which this data
was generated shows that, at the higher pressure, bubbles oscillate in a dramatically more non-linear
manner at BT than similarly sized bubbles at RT. This is particularly evident at resonance, with the
result that jetting, shell fragmentation and gas expulsion are more likely to occur at BT. Due to these
violent effects, purely spherical expansion of resonant bubbles no longer occurs, and the shell no longer
encapsulates the gas core, hastening bubble dissolution.
Repeat insonation of single bubbles supported these findings. At RT a gradual decrease in resting
diameter was seen with each subsequent excitation, as expected due to diffusion (Borden and Longo
2002). In contrast at BT, bubbles were frequently (33%) destroyed following the first insonation burst.
Of the bubbles which did survive, a fivefold greater decrease in mean bubble diameter was seen as
compared to RT, and no bubbles survived the second insonation burst.
Maximum Bubble Excursion (um)
Maximum Bubble Excursion (um)
Poly. (RT)
Poly. (BT)
R² = 0.963
R² = 0.961
Initial Bubble Diameter (microns)
Initial Bubble Diameter (microns)
Figure 1 Maximum bubble excursion plotted against initial bubble diameter at room (20°C) and body (37°C) temperatures
during (a) low MI excitation (~40 kPa) and (b) high MI (~100 kPa) excitation.
High speed observation of single bubbles provides evidence and justification for our hypothesis,
generated as a result of bulk bubble investigation, i.e., that acoustic behaviour is dominated by bubble
- 68 -
diameter changes due to increasing temperature. In addition to this, increasing the temperature to
approach the phase transition temperature of the phospholipid shell material, compromises the ability of
the shell to contain the gas within the bubble, resulting in decreased stability of both static and
acoustically driven bubbles. This effect is more noticeable at higher driving pressures, where the shell
is not able to support the large amplitude non-linear oscillations which result.
High speed optical imaging has improved our understanding of the differences in behaviour between
bubbles at RT and BT. In conclusion, investigation of USCAs should always be conducted at body
temperature if results are to be related realistically to in vivo applications.
The authors would like to thank Dr John Civale and Anna Tokarczyk (Institute of Cancer Research,
Sutton, UK) for their assistance with the hydrophone measurements.
This work was supported by an EPSRC grant (EP/F066740/1).
Borden MA, Longo ML, Dissolution behavior of lipid monolayer-coated, air-filled microbubbles: Effect
of lipid hydrophobic chain length. Langmuir 2002;18:9225-33.
Mulvana HE, Stride E, Hajnal J, Eckersley R. Temperature dependent behaviour of ultrasound contrast
agents. Accepted for publication in Ultras. In Med. And Biol.
- 69 -
Francesco Conversano1, Andrea Ragusa2, Antonio Greco1, Sergio Casciaro1
Institute of Clinical Physiology, National Council of Research, Lecce, Italy
National Nanotechnology Laboratory of CNR-INFM, Distretto Tecnologico ISUFI, Lecce, Italy
Nowadays, all contrast agents that are approved for clinical ultrasound imaging applications consist
of encapsulated gas microbubbles of a few micrometers1, able to produce strong signal backscatter
when insonified at frequencies belonging to the “diagnostic” range (typically 1-10 MHz). Since
microbubbles cannot leave the vascular space, they cannot reach cells located beyond the capillary
vasculature, such as many cancer cells. Actually, tumour angiogenesis vessels have the tendency to be
“leaky”2 and to exhibit the so-called EPR (enhanced permeability and retention) effect, which results in
exaggerated extravasation and retention of particles that are smaller than the pore size of tumour
endothelium (typically between 380 and 780 nm)3,4.
For these reasons, intensive investigations have been undertaken to develop nano-sized cancer
targeting agents for ultrasound molecular imaging5-9. The most significant experiments involving
nanoparticles (NPs) as ultrasound contrast agents were carried out on nanobubbles6, perfluorocarbon
nanodroplets7 and echogenic liposomes8. The use of solid NPs provides higher signal enhancement as
well as longer stability than liquid and gaseous particles of the same size. Nevertheless, ultrasound
investigations of solid NPs have been until now limited to very high frequencies (30-40 MHz)5,9, whose
clinical usefulness is restricted to few highly specific applications.
In this work we demonstrated the feasibility of using silica NPs as ultrasound contrast agents at
common diagnostic frequencies, by investigating the enhancement produced by varying particle
concentration and diameter in a range of clinical interest for tumour targeting and subsequent automatic
detection through radiofrequency (RF) signal analysis.
Silica was chosen as the elective material for this investigation because of its biocompatibility10-12,
ease of bioactive molecule encapsulation11, simplicity of nanoparticle formation12, and successful use as
drug delivery vector11,13. Silica NPs were synthesized in spherical shape with three different diameter
values (150 nm, 300 nm, 600 nm), considering that “ideal” NPs should be suitably stable in the
bloodstream without being detected and immediately removed by the reticuloendothelial system (RES).
In fact, NP size has to be bigger than 50 nm (size of intercellular openings in normal vessel walls) to
avoid non-specific distribution in the body, and not much bigger than 300 nm to escape as much as
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possible the RES trapping effects11 as well as to remain under the smallest reported value of tumour
endothelium pores (380 nm)3,4 for complying with targeting constraints.
Diagnostic power of the synthesized NPs was evaluated by studying ultrasound backscatter
behaviour when dispersed in agarose gel samples contained into Petri dishes: pure agarose gel was
essentially transparent to ultrasound, while silica NPs generated visible backscatter, already at low
concentrations. For each considered NP size, in fact, we tested samples containing variable volume
concentrations of dispersed silica NPs (up to 3%). Each prepared sample was imaged employing a
digital ecograph (Megas GPX, Esaote Spa, Florence, Italy), equipped with a linear transducer (LA523,
Esaote Spa) operating at 7.5 MHz and linked via optic fibre to a prototype platform for acquisition of
unprocessed RF data (FEMMINA, ELEN Spa, Florence, Italy). The ultrasound probe was mounted on
the motorized piston of an infusion pump (KDS 100, KD Scientific Inc., Holliston, MA, USA) and
automatically scanned along the sample. The sample was immersed in distilled water and the
transducer, in turn partially immersed in the water, was positioned perpendicular to the Petri dish
bottom at such a distance that the transducer focus (set to 2 cm) was located half-way through gel
depth. Each sample was scanned for 1 cm in its central part at a speed of 1 mm/min and 600 frames of
RF data were each time acquired (frame-rate = 1 fps). Echograph parameters were the same for all the
acquisitions: power = 50%, gain = 0 dB, linear TGC. Then, for each acquired frame, a rectangular
region of interest (ROI) composed of 100 echographic tracks with 90 points/track was positioned in the
central zone of the imaged gel section, so that the corresponding backscatter values were not influenced
by any boundary effect. The mean backscatter amplitude of each frame was calculated as the average of
the grey level values of the 9,000 pixels belonging to the ROI. The ultrasound backscatter amplitude
associated to each sample was the average of the 600 values resulting from the corresponding frame
Obtained results show that, for each considered NP size, the average grey level in the ROI increases
with NP concentration with a “logarithmic-like” trend, i.e. each grey level curve raises with
progressively decreasing slopes, up the reaching of a kind of “plateau”, then any further increment in
NP concentration does not produce any appreciable additional contrast enhancement. Therefore, we can
state that the maximum achievable enhancement is always less than 8 times the control brightness, with
a suitable value (between 4 and 6 times the control brightness) that can be reached by employing silica
NPs within the following ranges of volume concentration: 0.8-2.3% for 150-nm NPs; 0.2-0.4% for 300nm NPs; 0.4-0.8% for 600-nm NPs.
It is interesting to note that the lowest required NP concentration to obtain the same contrast
enhancement does not correspond to the biggest NP diameter (600 nm), but to 300-nm NPs. This is due
to the combined effect of number and diameter of NPs on the final image enhancement at the employed
ultrasound frequency. In fact, by analysing the contrast enhancement as a function of NP size for a
fixed volume concentration, image brightness always reaches its peak in correspondence of 300 nm.
- 71 -
This indicates that 150-nm NPs, although they are 8-fold as numerous as 300-nm NPs, are too small to
produce an effective ultrasound backscattering, while 600-nm have a reduced global scattering efficacy
being 8-fold less numerous with respect to 300-nm NPs, despite the increased diameter. Therefore, 300nm silica NPs present the most suitable combination of number concentration and diameter value to act
as powerful US scatterers with a low volume dose and at conventional diagnostic frequencies.
As a further goal of the present study, information available in the raw RF signal has been exploited
to automatically discriminate tissue target by means of silica NPs. A software for wavelet
decomposition and spectral analysis (RULES, ELEN SpA, Florence, Italy) has been employed to
develop a tailored colour map then applied to raw RF signals acquired through FEMMINA14. This
technique was applied on a different group of NP-containing agarose gel samples, synthesized just for
this specific purpose and consisting of Petri dishes filled with a layer of agarose gel containing silica
NPs placed between two different layers of pure agarose gel. One of these samples was prepared for
each of the considered NP sizes and all of them underwent the same echographic scansion previously
RF acquired data were off-line processed with RULES, in order to find a specific algorithm
configuration to selectively discriminate the NP-containing layer from the surrounding layers of pure
agarose gel. In particular, a different configuration was found for each tested NP size, employing each
time a different sub-group of the 25 parameters available in RULES, each parameter with its proper
settings. The final output of this algorithm was the superimposition on the initial B-mode image of a
specific colour map, capable of identifying the searched NPs in each of the acquired image frames.
Precision and accuracy of the adopted methodology was quantified through evaluation of
sensibility, specificity and Dice similarity coefficient (DSC)15, that were respectively: 16%, 98% and
20% for 150-nm NPs; 74%, 99% and 80% for 300-nm NPs; 63%, 98% and 69% for 600-nm NPs.
Therefore, also for quantitative tissue typing applications, 300-nm silica NPs showed an impressive
discrimination power in targeted tissues, significantly higher than the corresponding for smaller and
bigger particles of the same material.
In conclusion, this study demonstrated the feasibility of ultrasound molecular imaging by means of
silica NPs as contrast agents in the range of conventional diagnostic frequencies. The optimal size for
medical applications resulted of 300 nm with a volume concentration of 0.4%. Furthermore, these
contrast agents have been shown to provide a characteristic “signature” in the RF ultrasound signal, so
offering a unique diagnostic opportunity to automatically discriminate pathological from healthy tissues
with high prediction values.
This work was partially funded by the grant N° DM18604 – Bando Laboratori – DD MIUR 14.5.2005
n.602/Ric/2005 of the Italian Ministry of Instruction and Research.
- 72 -
Villanueva FS. Molecular imaging of cardiovascular disease using ultrasound. J Nucl Cardiol
Pasqualini R, Arap W, McDonald DM. Probing the structural and molecular diversity of tumor
vasculature. Trend Molec Med 2002;8:563-571.
Hobbs SK, et al. Regulation of transport pathways in tumor vessels: role of tumor type and
microenvironment. Proc Natl Acad Sci 1998;95:4607-4612.
Maeda H, Wu J, Sawa T, Matsunama Y, Hori K. Tumor vascular permeability and the EPR effect in
macromolecular therapeutics: a review. J Control Release 2000;65:271-284.
Liu J, et al. Nanoparticles as image enhancing agents for ultrasonography. Phys Med Biol 2006;51:21792189.
Wheatley MA, Forsberg F, Dube N, Patel M, Oeffinger BE. Surfacant-stabilized contrast agent on the
nanoscale for diagnostic ultrasound imaging. Ultrasound Med Biol 2006;32:83-93.
Dayton PA, et al. Application of ultrasound to selectively localize nanodroplets for targeted imaging and
therapy. Mol Imaging 2006;5:160-174.
Buchanan KD, Huang S, Kim H, MacDonald RC, McPherson DD. Echogenic liposome compositions for
increased retention of ultrasound reflectivity at physiologic temperature. J Pharm Sci 2008;97:22422249.
Liu J, Li J, Rosol TJ, Pan X, Voorhees JL. Biodegradable nanoparticles for targeted ultrasound imaging
of breast cancer cells in vitro. Phys Med Biol 2007;52:4739-4747.
Jin Y, Kannan S, Wu M, Zhao JX. Toxicity of luminescent silica nanoparticles to living cells. Chem Res
Toxicol 2007;20:1126-1133.
Barbè C, et al. Silica particles: a novel drug-delivery system. Adv Mater 2004;16:1959-1966.
Piao Y, Burns A, Kim J, Wiesner U, Hyeon T. Designed fabrication of silica-based nanostructured
particle systems for nanomedicine applications. Adv Funct Mater 2008;18:3745-3758.
Moulari B, Pertuit D, Pellequer Y, Lamprecht A. The targeting of surface modified silica nanoparticles to
inflamed tissue in experimental colitis. Biomaterials 2008;29:4554-4560.
Masotti L, et al. FEMMINA: real-time, radio-frequency echo-signal equipment for testing novel
investigation methods. IEEE Trans Ultrason Ferroelectr Freq Control 2006;53:1783-1795.
Massoptier L, Casciaro S. A new fully automatic and robust algorithm for fast segmentation of liver
tissue and tumors from CT scans. Eur Radiol 2008;18:1658-1665.
- 73 -
The acoustic response of individual microbubbles in tubes
Mairead Butler1, Aris Dermitzakis2, David Thomas1, Steve Pye3, Vassilis Sboros1
1. Medical Physics, Centre for Cardiovascular Research, University of Edinburgh, UK
2. University of Patras, Greece
3. Medical Physics, NHS Lothian, Edinburgh, UK
There are no specific ultrasound imaging techniques which allow the differentiation between
microbubbles in small vessels and large vessels in vivo. It is known that the presence of a tube wall
influences the acoustic response of microbubbles (Garbin 2007). Data describing the acoustic response
of individual, free microbubbles have previously been obtained using specifically designed
experimental equipment (Sboros 2003, Thomas 2009). The existing experiment system was modified to
allow the acoustic interrogation of microbubbles in mounted tubes. Cellulose based tubes of 200um
diameter and acrylic tubes of 180um and 50 um diameter were used with contrast agents Definity
(Lantheus Imaging) and BiSphere (Point BioMedical). Data for free bubbles subject to the same
acoustic field as the tube was also available and used for comparison. The transmit frequency was 1.6
MHz and the pulse 6-cycles. The acoustic pressure ranged from 160 to 1000 kPa
For all microbubbles the fundamental and harmonic RMS backscattered pressure was calculated. In all
tube sizes differences in the response of free microbubbles and microbubbles in tubes were observed,
with the difference becoming more pronounced in the narrower tubes.
For rigid shelled biSphere, in the 200um tube, the lifetime of the microbubbles, i.e. number of
consecutive pulses for which an echo was detected, was less than free biSphere microbubbles subject to
the same acoustic pressure, e.g. at 550 kPa insonation, 33% of biSphere microbubbles in the 200um
cellulose tube gave no echo after 7 consecutive insonations (1ms interval) whereas 7% of the free
microbubbles gave no echo. In the 200um tube at 550 kPa the mean fundamental RMS pressure was 2.1
+ 1.3 Pa compared to 4.7 + 3.7 Pa for free. In the 180um and 50um tube the harmonic response of the
biSphere was higher than in the 200um tube and for free microbubbles. For biSphere, microbubble
destruction increased with reducing tube diameter.
For lipid shelled Definity, there was an increase in the harmonic content of the microbubbles with
decreasing tube size. The mean fundamental RMS pressure for free microbubbles was 5.69 + 5.4 Pa and
2.72 + 1.35 Pa in the 50um tube. In 200 um diameter tubes, more microbubbles survived consecutive
- 74 -
pulses, e.g. at 300kPa, after 7 consecutive pulses, no signal was detected from 33% of Definity
microbubbles compared to 8% of microbubbles in the tube.
The size distributions of the microbubbles were assessed with the median value for free biSphere
microbubbles being 3.15 + 0.1 um and microbubbles in the 200um tube being 3.43 + 0.1 um in
diameter. This may explain part of the change in the observed acoustic behaviour.
Apart from the observed changes in the data presented here, the acoustic setup has shown that very
small changes in the microbubble population acoustic behaviour are possible to record. This work
provides valuable insight into the acoustic behaviour of microbubbles in tubes and might be useful for
further developing pulse sequences for detecting microbubbles in tubes.
Garbin V. et al., "Changes in microbubble dynamics near a boundary revealed by combined optical
micromanipulation and high-speed imaging," Appl Phys Lett 90 (11): 114103 (2007).
Sboros V. et al., "The behaviour of individual contrast agent microbubbles," Ultrasound in Medicine &
Biology 29 (5): 687-694 (2003).
Thomas D.H. et al., "Single Microbubble Response Using Pulse Sequences: Initial Results," Ultrasound
in Medicine & Biology 35 (1): 112-119 (2009).
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Investigating the nonlinear response of individual lipid
encapsulated microbubbles at high frequencies
Brandon Helfield1,2, Emma Huo2, Emmanuel Cherin2 and David Goertz1,2
Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
Sunnybrook Health and Sciences Centre, Toronto, Ontario, Canada
Microbubbles have been extensively employed in diagnostic ultrasound (f < 5MHz) to enhance the
signal from blood and thereby increase the contrast between blood and tissue. Recently, there has been
increasing interest in contrast imaging at higher frequencies; applications ranging from intravascular
imaging, ophthalmology and small animal imaging. It has been established that populations of small
lipid encapsulated microbubbles respond non-linearly at frequencies above 20 MHz. Despite these
advances, the underlying behavior of these small microbubbles and their individual acoustic response is
not well understood at these higher frequencies. Further understanding of these responses can lead to
better optimization of contrast agents, improved contrast detection strategies and to enable quantitative
data analysis of contrast images at high frequencies.
In this study, the acoustic response of individual bubbles from four types of lipid encapsulated agents
was investigated: Definity (Lantheus Medical Imaging), Micromarker (Bracco Research), and two inhouse fabricated agents. The former two agents were selected as they are widely used to perform
nonlinear imaging at high frequencies. The latter two agents were used to investigate the potential role
of shell microstructure on nonlinear microbubble behaviour and were prepared according to previously
reported procedures 1 to have either a heterogeneous shell microstructure (comprised of larger
condensed phase domains) or a macroscopically homogeneous structure. Experiments were conducted
on individual microbubbles adjacent to an agar surface. Bubbles were optically sized and insonified at
25 MHz to examine their subharmonic response. Peak negative pressure ranged from 28 KPa to 1.28
MPa with either 10% bandwidth Gaussian enveloped pulses or tapered rectangular pulses. The echoes
were then compared to simulations to gain insight into characteristics of nonlinear oscillations,
particularly with regard to the symmetry of bubble oscillations.
Micromarker was found to be highly effective at generating nonlinearities, with 100% of bubbles with
diameters between 1 and 3 µm (n=31) undergoing nondestructive subharmonic oscillations. Definity
was found to have a more heterogeneous response with 66% for bubbles sized between 1 and 2 µm, and
Borden et al., “Lateral Phase Separation in Lipid-Coated Microbubbles,” Langmuir 22, 4291-4297 (2006)
- 76 -
33% for bubbles between 2 and 3 µm showing subharmonic behaviour (n=50). In addition, the pressure
threshold for the onset of subharmonic generation was found to differ between these two agents. 71% of
the Micromarker bubbles that generated subharmonics had onset pressure levels between 89-119 KPa to
initiate subharmonics, while the majority of Definity (87%) had onset pressures between 147-473 KPa.
For the in-house agents, it was found that 44% of the coarse microstructure bubbles were non-linearly
active over a range of 1 to 3 µm (n=24), whereas only 15% of the homogeneous microstructure bubbles
were over the same range (n=59). The propensity for subharmonic generation and variability in pressure
thresholds for small lipid encapsulated microbubbles was therefore found to be highly sensitive to the
specific microbubble formulation. The results also suggest that shell microstructure may be an
important factor responsible for causing these heterogeneous responses. The phase relationship between
the fundamental and subharmonic components of the received nonlinear signals was then examined and
was found to be generally consistent between bubbles. A comparison of the measured and theoretical
phase relationships indicates that subharmonics at these frequencies are associated with highly
asymmetric oscillations.
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Wideband Harmonic imaging of ultrasound contrast agent
with a CMUT Probe
Anthony Novell and Ayache Bouakaz
UMR INSERM U930, CNRS ERL 3106 and Université François Rabelais, Tours, France
Aim: Upon suitable excitation, microbubbles generate different nonlinear components such as 2nd
harmonic, superharmonic or subharmonic components. Currently, due to the limited frequency
bandwidth of PZT transducers, only a single nonlinear component is selected and imaged. Today,
advantages of Capacitive Micromachined Ultrasonic Transducers (CMUTs) such as wide frequency
bandwidth could be used in nonlinear contrast imaging. However, the driving electrostatic force induces
a nonlinear behavior generating thus undesirable harmonic components. Thanks to compensation
methods, it is possible to considerably reduce these unwanted components by modifying the excitation
waveform and exploit CMUTs for nonlinear contrast imaging. Compensation methods consist in
transmitting, in addition to the fundamental excitation component, another frequency component in
order to suppress the nonlinearities from the source. These methods allow recovering only the
nonlinearities of the explored media and discriminating the harmonic generated by CMUT. We propose
in this study the exploitation of the wide CMUT bandwidth to enhance the response from microbubbles
by selective imaging of the 2nd harmonic and the subharmonic components concomitantly. This
wideband imaging technique should improve both contrast to tissue ratio (CTR) and signal to noise
ratio (SNR).
Methods: Experiments were performed using a 128 elements CMUT linear array probe centered at 4
MHz. The measured CMUT bandwidth at -6 dB was higher than 120%. The probe was connected to an
open scanner with arbitrary waveform transmitters (M2M, France). A 2-cycle excitation Gaussian pulse
of 2 MHz at 700 kPa and 60% bandwidth was transmitted. First, optimal parameters for compensation
of the nonlinearities of the probe (e.g, phase or amplitude) were estimated using hydrophone
measurements in order to reduce the 2nd harmonic component generated by the CMUT probe. Then,
contrast agent harmonic imaging was performed using a 1/2000 diluted solution of SonoVue®
microbubbles in a flow phantom. Selective imaging at a wide frequency band including both the second
harmonic (at 4MHz) and the subharmonic (at 1MHz) components was performed. Imaging
performances were evaluated in terms of CTR and SNR.
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Results: Hydrophone measurements show that the CMUT generates a 2nd harmonic level only 6 dB
below the fundamental level at 2MHz. After compensation, we achieve a 16 dB reduction of the 2nd
harmonic component. Applying the compensation technique showed that the CTR at the 2nd harmonic
band increased by 11 dB. Taking advantage of the wide band of the probe, the compensation procedure
was applied to image both the 2nd and the sub harmonic concomitantly. Compared to subharmonic
imaging alone, the addition of the 2nd harmonic component provides an increase of the SNR by 6.53 dB.
The results are shown in the figure below.
Conclusion: These results demonstrate the ability to increase both CTR and SNR when wide band
imaging is performed in combination with CMUT probes.
2nd harmonic imaging (2/4 MHz) without
2nd harmonic imaging (2/4 MHz) after compensation
Wideband nonlinear imaging (2nd harmonic +
Subharmonic imaging (2/1 MHz)
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Subharmonic spectroscopy of ultrasound contrast agents
Telli Faez, Margreet Docter, Nico de Jong
Biomedical Engineering, ErasmusMC, the Netherlands
[email protected]
Atherosclerosis leads to the formation of multiple plaques within the arteries. Rupture of
vulnerable plaque causes thrombosis, which rapidly slow or stop blood flow leading to a heart attack or
stroke. The aim of this research is the early detection of vulnerable plaque by 3D ultrasound. For this
reason a 2D matrix probe is designed with the frequency bandwidth of 5 to 10 MHz. Contrast agents are
used to enhance the intensity of blood over tissue for better resolution and the subharmonic mode is
chosen due to higher contrast to tissue ratio (CTR) [1]. In this study, the behavior of contrast agents was
investigated for our specific frequency range, which is outside the commonly used range [2].
Material and methods
A highly diluted portion of BR14 contrast agent microbubbles (Bracco Research S.A., Geneva,
Switzerland) was insonified with a transducer at frequency range of 2-7 MHz with step size of 200 kHz.
The experiment was repeated in three acoustic pressures at focus: 50, 100 and 120 kPa. The response of
the bubbles was recorded with the ultrafast recording camera (Brandaris 128). 30 single bubbles with
approximate diameters between 1.5 to 5 μm were recorded. The diameter of the bubbles as a function of
time (DT-curve) and the corresponding power spectra were determined. From the DT-curves the
amplitude of excursion at transmitted frequency and half that frequency was calculated. The results
were fitted to the response of a harmonic oscillator and the resonance frequency of corresponding
bubble was extracted.
30% of studied bubbles showed subharmonic scattering. These bubbles had the diameter between
2.5 and 4.5 μm. Figure (1) shows the resonance frequency of a 4.4 μm bubble at 2.7 MHz at 50 kPa and
the shift towards lower frequencies by increasing the pressure.
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Fig 1- Resonance curve (Amplitude vs. frequency) of 4.4 μm diameter bubble and fit with the resonance curve for a dumped
harmonic oscillator driven by a sinusoidal forcing (Lorentzian function) fres= 2.7, 2.23 and 2.15 MHz for 50, 100 and 120 kPa
In order to study subharmonic signal of this contrast agent in the frequency range of designed 2D
probe (5-10 MHz) the experiments have to be repeated for transmitting frequencies double the
bandwidth of the transducer. At the moment we are limited with the speed of Brandaris to reach this
goal. Although, similar experiments on smaller bubbles at higher frequencies up to 12 MHz are in
Shankar, US Med&Bio 24, p395, 1998
Steven B. Feinstein, Am J Physiol Heart Circ Physiol 287:450-457, 2004
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Ultra high-speed fluorescence imaging of ultrasoundtriggered local drug release
Erik Gelderbloma, Klazina Kooimanb, Marcel Böhmerc, Nico de Jongab, Detlef Lohsea, and
Michel Versluisa
Physics of Fluids Group, University of Twente, Enschede, The Netherlands
Biomedical Engineering, Erasmus MC, Rotterdam, The Netherlands
Philips Research, Eindhoven, The Netherlands
[email protected]
Detailed knowledge on the complex dynamics of ultrasound contrast agents has been gained through
the use of the Brandaris 128 high speed imaging facility[1]. The non-linear behavior of coated bubbles,
including an enhanced subharmonic response and ‘compression-only’ behaviour[2] as a result of shell
buckling[3] were discovered by combining bright field microscopy with high-speed imaging at frame
rates at a tenfold of the driving ultrasound frequency. A major drawback of such a visualization method
is the poor contrast of the bubble wall due to a complex interplay of refraction and scattering of the
light transmitted in back-illumination. In addition, bright field imaging lacks the ability to distinguish
between liquid media with similar refractive index, which is crucial for the visualization of drug
Fluorescence microscopy does not suffer from the above shortcomings. Figure 1 shows a microcapsule
(Philips Research[5]) imaged both in bright field and in fluorescence. The latter shows a distinct
delineation of the wall boundaries and in addition a high contrast is achieved between the fluorescent
liquid core and its surroundings. However, the nanoseconds timescales at which bubble oscillations,
rupture and release take place makes time-resolved fluorescence imaging extremely challenging.
Figure 1 – Microcapsule imaged in bright field and in fluorescence (radius 2.5 μm).
Experimental setup
The excitation light source is a high power CW laser to maximize the fluorescence signal. An acoustooptic modulator controls the pulse length and avoids overexposure and heating of the (biological)
sample. The fluorescence emission is captured by the objective and is coupled into the camera. The
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microcapsules were recorded with a frame rate of up to 10 million frames per second, giving a unique
insight into the physical mechanisms of local intravascular drug delivery.
Figure 2 – Schematic of the experimental setup.
Phospholipid-coated microbubbles with a perfluorobutane gas core were produced in-house (method
described by Klibanov et al.). The fluorescently labeled microbubbles were driven by ultrasound at a
frequency of 500 kHz and were recorded at a frame rate of 2 million frames per second. The
fluorescence recordings show a higher contrast and enhanced details of the shell, as compared to the
bright field recordings.
Oil-filled polymeric microcapsules (Philips Research[5]) with a high dye concentration mixed in the
hexadecane liquid core demonstrate a photo-acoustic effect when excited with a laser intensity of just 1
MW/cm2. The dye molecules absorb the laser light leading to intense heating of the liquid core. Rapid
vaporization leads to expansion and finally the vapor starts to oscillate with a typical frequency of 200
kHz. Figure 3 shows several frames from the fluorescence recording of the vapor bubble dynamics.
Figure 3 – Fluorescence recording (3 Mfps) of the photo-acoustic effect of an oil-filled microcapsule. Bright field images
show the initial and final state.
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Ultra high-speed fluorescence imaging is a powerful tool for the visualization of the instantaneous
dynamics of coated bubbles. Drug release, its flow and resulting transfection can be observed at
nanoseconds timescales.
1. Chin CT, Lancee C, Borsboom J, Mastik F, Frijlink M, de Jong N, Versluis M, Lohse D. Rev Sci Instru,
74 (2003).
2. N. de Jong, C.T. Chin, A. Bouakaz, F. Mastik, D. Lohse, and M. Versluis, Ultrasound Med.Biol. 33, 653
3. P. Marmottant, S. van der Meer, M. Emmer, M. Versluis, N. de Jong, S. Hilgenfeldt, D. Lohse, J. Acoust.
Soc. Am. 118 (2005).
4. A.L. Klibanov, P.T. Rasche, M.S. Hughes, J.K. Wojdyla, K.P. Galen, J.H. Wible, and G.H.
Brandenburger, Detection of Individual Microbubbles of Ultrasound Contrast Agents: Imaging of FreeFloating and Targeted Bubbles, Invest. Radiol., vol. 39, pp. 187-95 (2004).
5. M.R.Böhmer, R. Schroeders, J.A.M. Steenbakkers, S.H.P.M. de Winter, P.A. Duineveld, J.Lub, W.P.M.
Nijssen, J.A. Pikkemaat, and H.R. Stapert, Preparation of monodisperse polymer particles and capsules
by ink-jet printing, Colloids and Surfaces A, 289, 96–104 (2006).
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Parametric Ultrasound Contrast Imaging with a MicroUltrasound System:
A Reproducibility Study in Mice
A. Needles1, T. Coulthard1, N. Rognin2, M. Arditi2, L. Mercier2, P. Frinking2, and
F.S. Foster1,3
1. VisualSonics, Toronto, Canada
2. Bracco Research SA, Geneva, Switzerland
3. Sunnybrook Research Institute, Toronto, Canada
This study focuses on the reproducibility of microbubble kinetics quantification in small animals, as
assessed by a new software program developed for that purpose. This quantification software uses
image sequences from a newly developed nonlinear contrast imaging mode on a micro-ultrasound
system (Needles et al. 2009), applies curve-fitting with a perfusion model function to the acquired
image sequence, and displays parametric images which map various parameters related to blood flow in
perfused tissues. This study was conducted on assessing renal blood perfusion in the kidneys of healthy
adult mice using the new quantification software tools. This should ultimately provide a set of baseline
results which pre-clinical researchers can use as a guide to assess reproducibility in their in vivo
perfusion studies using contrast imaging in mice.
A micro-ultrasound system (Vevo 2100, VisualSonics) was operated at 18 MHz in Nonlinear Contrast
Mode, with a 256 element linear array transducer (MS-250, VisualSonics, fc = 21 MHz, 70% -6dB twoway bandwidth). In vivo imaging was conducted with MicroMarkerTM (VisualSonics) contrast agent in
the kidneys of healthy adult mice. Five female mice (average weight = 23.2 ± 1.8 g) and five male mice
(average weight = 33.8 ± 3.1 g) were administered a single 50-µl bolus of contrast agent (1.2·107
bubbles per bolus). Heart rate (HR), body temperature (T), and respiratory rate (RR) were monitored
throughout the injection of the contrast agent and after its subsequent washout to ensure they were
within normal limits (HR = 400-500 bpm, T = 35-37 °C, RR = 1-2 Hz). The scan plane was oriented
from the dorsal side of the mouse, through a long section of the kidney. The scan plane was chosen to
encompass as much of the kidney cortex and medulla as possible for assessing the perfusion of the
microcirculation, while avoiding the larger renal blood vessels. Regions of interest (ROI) were placed
in the medulla and the cortex. Time intensity curves (TIC) of relative echo-power obtained by
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linearization of video signals (Rognin et al. 2008) were fitted for the different regions with a dedicated
bolus model, using prototype quantification software (Bracco Research SA, Geneva). Parameters
related to blood volume and flow (Peak Enhancement (PE), Wash-In Rate (WiR) and Rise Time (RT))
were obtained from the model fits within each ROI. The values of these parameters were recorded for
each ROI, as well as the ratios between the two ROI (cortex/medulla). The rationale for quantifying the
ratio stems from the fact that many researchers are interested in relative cortical vs. medullary flow
when assessing renal function and response to treatments (Franchini and Cowley 1996; Mattson and
Meister 2005). The software also generated parametric images from the model fits, which depicted
spatial distributions of calculated parameter values. These parametric images were generated by curvefitting the TIC in each pixel with the model function, in order to generate one parametric image for each
given parameter. The parametric images of RT were used to manually segment the ROI placement for
the regions within the medulla and cortex, as clear delineation was possible due to the different kinetics
within these two tissue types (see Fig.2d as an example). Finally, the Coefficient of Variation (CV) (i.e.
the ratio of standard deviation to the mean) for each parameter was expressed as a percentage for the set
of female mice, male mice, and all mice grouped together.
Fig. 1 shows representative Nonlinear Contrast images of a female mouse at various instants during a
contrast bolus.
Fig. 1 – Nonlinear Contrast imaging sequence at various instants during a contrast agent bolus in a female mouse kidney. BMode images of the kidney (left) are displayed side-by-side with the Nonlinear Contrast images (right).
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The TIC and parametric images of PE, WiR, and RT for the same animal are illustrated in Fig. 2 with
the ROI shown on the parametric image of RT.
Fig. 2 – Time-Intensity curves (a) for a contrast bolus in a female mouse (from Fig. 1). The curves represent perfusion kinetics
in the whole kidney (green), cortex region (magenta) and medulla region (yellow). Parametric images of the whole kidney
depict spatial variations in Peak Enhancement (b), Wash-In Rate (c) and Rise Time (d).
In terms of reproducibility, the group of female mice had a CV < 30% in all regions and for all
parameters, and in the case of RT the CV was < 20% (see Fig 3). For the male mice (Fig. 4), the CV of
the amplitude-based parameters (i.e. PE and WiR) were higher in both the cortex and medulla (< 40%)
than the female group. The RT in both the cortex and medulla was similar for both groups. Overall,
when grouping all mice together, the worst-case CV was 30%, for the cortical WiR (see Fig. 5).
Fig. 3 – Coefficient of Variation (CV) for Peak Enhancement (PE), Wash-In Rate (WiR) and Rise Time (RT) for
the group of female mice. CV is calculated for the cortex region (blue), medulla region (red) and the ratio of
cortex/medulla regions (green).
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Fig. 4 – Coefficient of Variation (CV) for Peak Enhancement (PE), Wash-In Rate (WiR) and Rise Time (RT) for the group of
male mice. CV is calculated for the cortex region (blue), medulla region (red) and the ratio of cortex/medulla regions (green).
Fig. 5 – Coefficient of Variation (CV) for Peak Enhancement (PE), Wash-In Rate (WiR) and Rise Time (RT) for the group of
all mice. CV is calculated for the cortex region (blue), medulla region (red) and the ratio of cortex/medulla regions (green).
Discussion and Conclusions:
In general, it is clear that the time-based parameter (RT) was the most reproducible quantity in all cases.
This was also shown to be the case in a similar study in sheep (Strouthos et al. 2009). Utilizing the RT
parameter as much as possible for in vivo quantification of blood perfusion is recommended for preclinical imaging in mice. An interesting finding was that the RT within the medulla showed more
variability than within the cortex. On the contrary however, the amplitude-based parameters (PE and
WiR) showed more variability in the cortex than in the medulla, and more variability in males than in
females. This could perhaps be explained by the fact that the sizes of the kidneys for the female mice
were much more consistent, leading to a more reproducible imaging plane. In the case of the males, the
larger kidneys spanned a wider range of depths in the image, leading to a larger dependence on
attenuation and beam profile effects. This was evident in the level of background tissue signal in the
male mice which was more variable than in the females (not shown). This would lead to more
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variability in the calculation of amplitude-based parameters. Finally, the variation in the ratios of the
cortex to medulla parameters were all within 30%, a finding that will potentially be useful to
researchers studying kidney function or targeting therapies designed specifically for either medullary or
cortical flow. Knowing the variability in such studies is important for estimating the smallest changes in
physiological parameters that can realistically and reliably be detected.
Important to note is that these experiments were conducted with a manual bolus injection. It is hoped
that with improved experimental technique, specifically the implementation of a bolus injection pump,
the reproducibility of the measured parameters could be improved even further. A second important
aspect of this study, i.e. the investigation into the reproducibility of repeated injections within a single
animal, is currently underway. This will help to determine what component of the variation presented
here is intrinsic to the experimental technique (i.e. preparation and injection of the contrast agent),
rather than caused by variability in the physiology of a particular animal. Finally, additional parameters
such as Area Under the Curve (AUC), Time to Peak (TTP), Mean Transit Time (MTT) and Perfusion
Index (PI), which have not been presented here, are currently being analyzed and will be discussed.
Franchini KG, Cowley AW. Renal Cortical and Medullary Blood Flow Responses During Water
Restriction: Role of Vasopressin. Am J Physiol Regul Integr Comp Physiol 1996;270:R1257-R1264.
Mattson DL, Meister CJ. Renal Cortical and Medullary Blood flow Responses to L-NAME and ANG II
in Wild-type, nNOS Null Mutant, and eNOS Null Mutant Mice. Am J Physiol Regul Integr Comp
Physiol 2005;289(4):R991- R997.
Needles A, Mehi J, Arditi M, et al. Nonlinear Contrast Agent Imaging with a Linear Array Based MicroUltrasound System. Proc IEEE Ultrason Symp, 2009. In press.
Rognin NG, Frinking P, Costa M, Arditi M. In-vivo Perfusion Quantification by Contrast Ultrasound:
Validation of the Use of Linearized Video Data vs. Raw RF Data.
Proc IEEE Ultrason Symp 2008:1690-1693.
Strouthos C, Lambaskis M, Sboros V et al. Quantification of the Microvascular Blood Flow of the Ovine
Corpus Luteum with Contrast Ultrasound. Proc IEEE Ultrason Symp, 2009. In press.
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An In Vivo Model for Real Time Visualization of
Microbubble-Mediated Sonothrombolysis in the
John Pacella, MS, MD; Francois Yu, PhD; Xucai Chen, PhD; Jonathan Leeman, BS;
Linda Lavery, BS; and Flordeliza Villanueva, MD
Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, University of
Pittsburgh, Pittsburgh, PA
Occlusive coronary artery thrombus results in compromised myocardial perfusion and underlies
myocardial infarction.
Effective mechanical strategies for rapid clot removal from the epicardial
coronary arteries have been developed.
However, these approaches often result in distal
microembolization of the thrombus, resulting in failure of microvascular reperfusion to the infarct zone
despite restoration of epicardial coronary artery patency.
Strategies for dissolution of diffusely
dispersed thrombi from the microcirculation are limited, and ideally should be regionally targeted to the
infarct territory.
Ultrasound mediated microbubble destruction is a potentially attractive approach to
achieving microvascular thrombolysis.
However, optimal ultrasound parameters and microbubble
properties have yet to be defined and an in vivo model for systematic assessment of such parameters is
Furthermore, in vitro test systems do not reproduce the time-dependent endogenous
fibrinolytic pathways that likely interact with the sonothrombolytic process. Herein, we propose a
novel in vivo system that will not only allow for the pinpoint generation of microvascular thrombi, but
will also allow application of contrast enhanced ultrasound during continuous direct observation of
microvascular thrombi using intravital microscopy.
We have performed 8 preliminary studies which demonstrate the feasibility of this approach. Our
system is comprised of an Olympus BX 51 compound upright microscope with a Gibraltar stage. Rats
were anesthetized and the cremaster muscle was exteriorized and placed on a customized stage for
intravital microscopy. Various sized arteriolar thrombi were created by cannulating the vessel with a 25 μm tipped glass micropipette using a motorized Burleigh micromanipulator. Ultrasound was then
applied to the preparation by positioning a 2 F ultrasound catheter (Ekos) within 2 mm of the
microvascular thrombi. The catheter was driven by a pulse generator (Agilent) and a power amplifier
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(Amplifier Research).
Duty cycle (0.1-20%), pulse repetition frequency (PRF 1-10 Hz), and
mechanical index (MI 0.07-1.0) were varied. Lipid encapsulated perfluorobutane microbubbles were
intravenously infused during simultaneous application of ultrasound and intravital microscopic
The system allowed for direct observation of the thrombus during administration of contrast enhanced
ultrasound. The figure below depicts thrombus behavior in a single arteriole during one study.
In the
panel on the left, the thrombus was occlusive and large, and there was no flow in the arteriole. After
the application of ultrasound during infusion of microbubbles (MI of 0.07, duty cycle of 20%, PRF of 1
Hz), thrombus dissolution and recanalization of the occluded artery were directly observed in real time
(right panel).
With manipulation of acoustic variables, other phenomena, such as reversible
microvascular constriction, could be observed.
This experimental model allows direct, real time observation of microvascular thrombi during the
application of contrast enhanced ultrasound in a physiologic in vivo environment. Such an approach
should help to guide the selection of optimal ultrasound and contrast parameters for successful
microvascular thrombus dissolution, with the ultimate goal of restoring microvascular perfusion.
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Ultrasound and Microbubble enhanced cell permeability
through generation of transient sub-micron disruptions on
the plasma membrane: Transmission electron microscopy
Raffi Karshafian , Peter N. Burns
Department of Medical Biophysics, University of Toronto Department of Physics, Ryerson University,
Canada Imaging Research, Sunnybrook Health Sciences Centre, Canada
The application of ultrasound with microbubbles increases cell membrane permeability and allows
molecules to cross the otherwise-impermeable plasma membrane and enter the intracellular space of
cells, a phenomenon referred to as sonoporation. Studies have been performed with the aim to optimize
ultrasound and microbubble parameters to improve the delivery of drugs/genes into cells. As part of that
effort, our group have identified exposure conditions which resulted in enhanced permeability in ~70%
of the cells while maintaining cell viability (as assessed with propidium iodide marker). The primary
mechanism underpinning sonoporation has been demonstrated to be the formation of non-lethal and
transient pores on the cell membrane. However, in addition to the transient membrane disruption
mechanism, endocytosis, which is a biological internalization process, has been shown to facilitate
intracellular delivery at low ultrasound exposure conditions. In this study, the underlying mechanism
associated with enhanced permeability was investigated under high MI ultrasound exposure conditions
with the objective of quantifying the distribution of disruptions generated by ultrasound and
microbubbles on the cell membrane.
KHT-C cells in suspension were exposed to ultrasound pulses of 500 kHz centre frequency, 570kPa
peak negative pressure, 32µs pulse duration, 3kHz pulse repetition frequency and 5s insonation time
with and without Definity microbubbles (3.3% v/v). Cell permeabilisation was assessed with 70kDa
FITC-dextran. Plasma membrane morphology was observed with electron microscopy. Cell
permeability of 71% was achieved by ultrasound and microbubbles with the FITC-dextran added 60s
before ultrasound exposure. Permeability similar to control (0.5%) was achieved with ultrasound alone
(2%), and with FITC-dextran added 60s following termination of ultrasound and microbubble treatment
(0.6%). Untreated cells exhibited continuous plasma membrane morphology as assessed with
transmission electron microscopy (TEM). TEM images of cells treated with ultrasound and
microbubbles revealed disruptions on the plasma membrane generally ranging from 30 to 100 nm and
as large as 400 nm, immediately (i.e., within 2s) following termination of ultrasound. No disruptions
were observed on cells one minute after termination of ultrasound and microbubble treatment, and on
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cells treated with ultrasound alone. The presence of disruptions on the cell membrane was consistent
with the intracellular uptake of FITC-dextran molecules. This study demonstrated that the biological
mechanism underpinning sonoporation is the generation of transient sub-micron disruptions on cell
membranes by ultrasonically stimulated microbubbles.
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Acoustic sizing of an ultrasound contrast agent
David Maresca 1, Marcia Emmer 1, Paul L. M. J. van Neer 1, Hendrik J. Vos 1, Michel
Versluis 2, Marie Muller 1, 3, Nico de Jong 1, 4, Antonius F.W. van der Steen 1, 4
Department of Biomedical Engineering, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands
Physics of Fluids group, Twente University, the Netherlands
Institut Langevin, Université Paris Diderot, ESPCI ParisTech, Paris, France
Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
Ultrasound contrast imaging depends largely on the harmonic behavior of bubbles. It is acknowledged
that bubble size has a great impact on the amount of harmonic generation. However the size distribution
of the contrast bubbles after administration to patients is largely unknown. High above resonance,
bubble responses depend on their physical cross section only [1]. Our objective is to take advantage of
this feature to measure single bubble sizes with ultrasound.
A 25 MHz single element focused transducer (2.6 cm focus) was mounted in a water tank. A highly
diluted population of the ultrasound contrast agent DefinityTM was injected in a 200 μm diameter
cellulose capillary that crossed the transducer beam focus inside the water tank. A microscope equipped
with a 40x water immersion lens and a CCD camera was added to record images of the capillary region
of interest where the acoustic beam is focused. The pressures scattered by single bubbles responding to
400 kPa pulses (MI < 0.1) were acquired. The transducer was calibrated both in transmission and
reception so that real pressure values could be derived from the measurements. At a frequency high
compared to the bubble resonance frequencies, the backscattered pressure ps relates to the bubble radius
R as ps = R·pi/z , where z is the transducer-bubble distance and pi the incident pressure hitting the
We sized one by one 88 DefinityTM bubbles from the same vial both acoustically and optically. The size
distribution obtained acoustically showed a mean diameter (2.5 µm) and a standard deviation (0.9 µm)
in agreement within 8% with the optical reference measurement (Figure 1). Both results are in
agreement with the size distribution claimed by the manufacturer (Table 1).
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Optically measured size distribution
Number of bubbles
Diameter [mm]
Acoustically measured size distribution
Number of bubbles
Diameter [mm]
Table 2. DefinityTM size distribution, Lantheus Medical Imaging®
The acoustically determined size distribution is comparable in shape with the optically determined
distribution and only appears very slightly shifted to lower radii. The 12% uncertainty of the
hydrophone used to calibrate the transducer could be a reason for the observed shift. The random
disparities between the two distributions may originate from the different position each bubble had
within the transducer focal spot. We expect as well that the capillary affects the transducer pressure
field, creating hot pressure spots within the tube. An application of our method could be to analyze
bubbles administered in superficial arteries (e.g. carotid artery) as it potentially estimates the size
distribution of a bubble population noninvasively.
[1] J Sijl, et al., “Acoustic characterization of single ultrasound contrast agent microbubbles”, JASA, 2008
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Towards an ultrasound contrast method for
imaging extavascular molecular targets
Tom H. Shorrock and Jeffrey C. Bamber
Joint Department of Physics, Institute of Cancer Research and
Royal Marsden Hospital, Downs Road, Sutton, Surrey, SM2 5PT, UK
The use of resonant and non-linear scattering from micron-sized bubbles insonated at frequencies in the
low megahertz range has worked well for adding contrast to depict vasculature in clinical ultrasound
images and improve the measurement of blood flow. Such bubbles may also be functionalised to target
specific molecular markers but are restricted to the vasculature due to their size, which is hard to
change. This limitation will prevent ultrasound from developing into a full molecular imaging modality.
If it could be overcome, ultrasound would have a major role to play in molecular imaging, because of
its cost effectiveness, its excellent temporal and spatial resolution, and its potential for extremely high
sensitivity to the contrast agent.
Here we report preliminary studies of a combined contrast agent and imaging concept, based on a
perfluorocarbon emulsion with a drop-size small enough (less than about 150 nm) to leave blood
vessels, and who's drops can be transiently vaporised acoustically to create bubbles on the other side of
the blood vessel wall. The method relies on two synchronised acoustic waves, one at a low-frequency to
vaporise the oil and manipulate the resulting bubbles for imaging, and one at a high-frequency that
images them. The use of a relatively short activating/manipulating wave and its accurate
synchronisation with the imaging wave resembles in some respects the technique of SURF imaging1,
and it distinguishes this work from previous perfluorocarbon droplet vaporisation-based imaging
Experiments were carried out with a novel arrangement where the low frequency and high frequency
transducers face each other to produce co-axial and co-focal beams of waves travelling in opposite
directions. The two acoustic waves, the vaporising/manipulating wave at 0.5 MHz and the imaging
wave at 20 MHz, pass though each other in the sample at the same time, at a position and over a
distance determined by the synchronisation and the low frequency burst length (between 5 and 40
cycles). If the low frequency wave has induced bubbles to appear, the high frequency imaging pulse (23 cycles) will interact with them at different sizes for different depths. Thus, with data from a single
pair of pulses, the depth dependence of the echo signal allows the high frequency acoustic backscatter
to be studied as a continuous function of phase of the vaporising/manipulating wave. This arrangement
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was implemented with two systems. First, both transducers were stationary, so that the time evolution
of the high frequency backscatter along a single line could be studied. Second, a Cortex Dermascan™
ultrasound scanner was used to scan the high frequency transducer mechanically, to produce about 4
pairs of B-scans per second, within which a central region was illuminated by the low frequency beam;
the pairs of images were formed by pulsing the high frequency transducer twice for each image line,
once with the synchronised low frequency burst on and once with it off.
Preliminary studies were carried out with commercial microbubbles (Levovist™ and Sonovue™), to
determine whether in the above experiment an influence could be observed of the low frequency wave
pressure on the high frequency scattering cross-section. As the pressure of the manipulating wave was
increased, evidence of very high frequency harmonic forward scattering was observed, as too was
bubble destruction/cavitation, but no clear evidence of a pressure dependent scattering cross-section
was immediately obvious at 20 MHz.
This prompted a number of theoretical studies. In particular, the Keller-Miksis equation was used to
calculate the time variation of the microbubble radius for free gas bubbles, and hence the depth
dependence of the 20 MHz scattering cross-section in the above experiment. It was found that for a
single resting bubble size, pronounced increases in 20 MHz scattering cross-section were predicted
during the compression phase of the manipulating wave, as the bubbles pass through resonant size,
whereas when the calculations were repeated for a realistic weighting of bubble sizes this resonance
effect was smoothed out so that only a small residual increase in the 20 MHz scattering cross-section
remained, now at the rarefaction phase of the manipulating wave and apparently due only to the change
in geometrical scattering cross-section. This may explain the above experimental results.
Samples of water and a perfluoropentane (boiling point 28 deg C) emulsion manufactured by sonicating
the oil in lecithin and degassed water before passing it through a 200nm filter, were also studied in the
above experiment. Vaporisation of this simple emulsion was demonstrated, as observed by transient but
bright signals on the 20 MHz images appearing at the focus of the low frequency wave. Interestingly, in
the first of the above experimental arrangements, bands of highly localised high frequency echo signals
were also found, at the spatial period of and in the rarefactional regions of the low frequency wave.
These echo signals were observed at lower drive pressures for the emulsion than for water, and they coexisted with audio frequency emissions that were similar to those observed for cavitation. The echoes
themselves were short duration events, appearing to have poorer temporal and spatial correlation than
would be expected from the 20 MHz point spread function.
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These preliminary results extend previous work on perfluorocarbon droplet vaporisation, suggesting
that exceptionally short duration droplet cavitation events may be induced and that a SURF imaging
approach may have potential for imaging them. Further work will aim to confirm and quantify the
above observations and improve understanding of their variation with experimental conditions through
further modelling and experiment, and to extend the experiments using a multifrequency transducer that
will allow the vaporising/manipulating wave and the high frequency imaging wave to be launched from
the same location, as needed for eventual in vivo evaluation of the method.
Hansen R, Angelsen BAJ. SURF imaging for contrast agent detection. IEEE Trans UFFC, 2009;56:280290.
Asami R, Azuma T, Yoshikawa H, Kawabata K. Tumor enhanced imaging and treatment with targeted
phase-change nano particles, pp. 1973-1976 in: Proc 2007 IEEE Ultrasonics Symp, 1051-0117, New
York, IEEE, 2007.
Matsuura N, Gorelikov I, Williams R, Wan K, Zhu S, Booth J, Burns P, Hynynen K, Rowlands JA.
Nanoparticle-tagged perfluorocarbon droplets for medical imaging, Proc Mat Res Soc, 2008; DOI:
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Phase-shift nanoemulsion/microbubble platform for
ultrasound-mediated drug delivery
Natalya Rapoport
Department of Bioengineering, University of Utah, Salt Lake City, Utah, USA
Co-authors: Kwon-Ho Nam, Anne M. Kennedy, Jill Shea, Courtney Scaife
During the last decade, nanomedicine has evolved as a new field of oncology that holds promise of
solving hard problems of current cancer chemotherapy. Various drug nanocontainers and delivery
modalities have been suggested for increasing stability and aqueous solubility of chemotherapeutic
drugs and decreasing their systemic toxicity. Properly designed nanoparticles avoid extravasation to
normal tissues and recognition by reticulo-endothelial system cells, which prolongs their circulation
time and allows passive tumor targeting. Passive targeting is based on the enhanced permeability of
defective tumor microvasculature that allows extravasation of drug-loaded nanoparticles through large
inter-endothelial gaps; it was shown that in a variety of tumors, characteristic pore cutoff size ranges
between 380 and 780 nm, though in some tumors it may reach up to 2 μm. In contrast to tumors, blood
vessels in normal tissues have tight inter-endothelial junctions that don’t allow extravasation of
nanoparticles. In addition to enhanced vascular permeability, tumors demonstrate poor lymphatic
drainage; this positive effect provides for a long retention of the extravasated particles in tumor tissue.
This effect is called enhanced permeability and retention, or EPR.
An alternative approach to tumor targeting consists of developing stimuli-responsive nanoparticles
that release their drug load only in response to environmental or physical stimuli, such as pH,
hyperthermia, light, or ultrasound. Ultrasound as a component of a drug delivery modality is especially
attractive for reasons of cost-effectiveness and prospects for combining ultrasonic imaging and therapy.
Ultrasound may be applied with a variety of drug carriers. Ultrasound may be directed toward deeply
located body sites in precise energy deposition patterns. Sonication may be performed non-invasively or
minimally invasively through intraluminal, laparoscopic or percutaneous means.
For many decades, microbubbles have been used in clinical practice exclusively as ultrasound
contrast agents in ultrasound imaging. During the last decade, microbubbles have attracted attention as
drug carriers and enhancers of drug and gene delivery and are now being widely investigated for this
application. However, these systems present inherent problems. Their very short circulation time
(minutes) and micron size do not allow effective extravasation into tumor tissue, which is an essential
prerequisite for effective drug targeting.
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The way to solve above problems may consist in developing drug-loaded, nano-scaled microbubble
precursors that would effectively accumulate in tumor tissue by passive or active targeting and then
convert into microbubbles in situ after tumor accumulation. With this in mind, we have recently
developed block copolymer stabilized echogenic perfluorocarbon nanoemulsions. The core of
nanoemulsions was formed by either perfluoropentane (PFP) with a boiling point of 29 ºC at
atmospheric pressure or perfluoro crown ether-10 (PFC) with a boiling point of 140 ºC at atmospheric
pressure. The shell of nanodroplets was formed by biodegradable block copolymers poly(ethylene
oxide)-co-poly(lactide) (PEG-PLA) or poly(ethylene oxide)-co-polycaprolactone (PEG-PCL). Here, we
describe acoustic and therapeutic properties of these nanoemulsions that were explored in breast,
ovarian, and pancreatic cancer models.
Due to high mismatch between acoustic impedances of perfluorocarbon and water (or tissue), both
PFP droplets (~0.3 MRayl) and bubbles (<<0.3 MRayl) manifest echogenic properties; however
bubbles manifest much higher echogenicity than droplets, which creates better contrast in ultrasound
images. Even more importantly, only bubbles undergo high-amplitude oscillation and inertial cavitation
in an ultrasound field, which concentrates ultrasound energy and substantially enhances ultrasoundmediated drug delivery. Though drug delivery from micelles, liposomes, or emulsions may be
ultrasonically enhanced even without microbubbles, presence of microbubbles dramatically increases
intracellular uptake of drugs or genes. Therefore nanodroplet vaporization to generate bubbles would be
highly desirable for both ultrasonography and drug delivery.
We have identified three major factors that induced droplet-to-bubble transitions in PFP
nanoemulsions, namely heat, injection through thin needles, and ultrasound. In the presentation, these
factors will be discussed in detail for the droplets inserted in liquid emulsions or gels. Among those
listed, ultrasound was the most effective. Thermal transition was significantly hampered even for PFP
nanodroplets in liquid emulsions due to high Laplace pressure inside droplets. An example of
dependence of boiling temperature on droplet size for a PFP nanoemulsion is presented in Figure 1. At
physiological temperatures, PFP droplets with a diameter smaller than about 4 μm will not vaporize and
therefore will circulate as liquid droplets, which is important for their extravasation and tumor
accumulation. On the other hand, after ultrasound-triggered droplet-to-bubble transition, the bubbles
with a size larger than 4 μm will not condense back into the liquid state and will be preserved as
microbubbles, which is important for ultrasound imaging and drug release. If PFP were an ideal gas,
these bubbles would be formed from droplets of a diameter equal or larger than 800 nm.
The data presented in Figure 2 show that after systemic injections in vivo, drug (paclitaxel, PTX)
encapsulated in nanoemulsion was tightly retained by nanodroplets without ultrasound, but was
effectively released under the action of therapeutic ultrasound.
Examples of therapeutic efficacy of the proposed combined tumor therapy by drug-loaded
nanoemulsions and ultrasound are presented in Figures 3-5. The data of Figure 6 suggest nanodroplet
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accumulation in tumor after systemic injection. The data of Figure 7 show injection-induced droplet-tobubble transition in vitro and in vivo.
Advantages and limitations of the prospective clinical application of the described technique will be
Figure 1. Dropler vaporization temperature as a function of droplet size for the surface tension values of 30 mN/m and 50
Figure 2. Photographs of a mouse bearing two ovarian carcinoma tumors (A) - immediately before and (B) - three weeks after
the treatment; a mouse was treated by four systemic injections of nanodroplet-encapsulated PTX, nbGEN (20 mg/kg as PTX)
given twice weekly; the right tumor was sonicated by 1-MHz CW ultrasound (nominal output power density 3.4 W/cm2,
exposure duration 1 min) delivered 4 hours after the injection of the drug formulation. Ultrasound was delivered through a
water bag coupled to a transducer and mouse skin by Aquasonic coupling gel.
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Figure 3. Regression of ovarian carcinoma treated by the proposed technique as described for Figure 2.
The first photograph was taken before the start of the treatment, the second – two weeks later, i.e.
immediately after the completion of the treatment. The third photograph was taken one week after the
completion of the treatment.
Figure 4. Regression of the breast tumor treated by paclitaxel-loaded PFC nanoemulsion and focued 1-MHz ultrasound at a
nagative pressure of 1.5 Mpa.
Figure 5. Growth/regression curves of pancreatic cancer treated by micelle or nanodroplet encapsulated paclitaxel and
unfocused 1-MHz ultrasound.
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Fig. 6. Ultrasound images of a pancreatic tumor before (left) and 5.5 h
after systemic injection of paclitaxel-loaded PFP nanoemulsion (right).
Figure 7. Ultrasound images of nanodroplets/microbubbles;
A – water in a test tube; B - PFP/PEG-PCL nanodroplets in a test tubes,
C – PFP/PEG-PCL nanodroplets injected into agarose gel through a 26 G needle;
D - PFP/PEG-PCL nanodroplets injected into a subcutaneous pancreatic tumor through a 26 G needle.
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New developments in therapeutic applications of
microbubbles: an update
Raffi Bekeredjian
Gas filled microbubbles have emerged as a new tool for site specific gene and drug
delivery. This is based upon two distinct characteristics of microbubbles exposed to ultrasound:
the ability to unload a previously loaded bioactive substance and the ability to transiently
increase capillary permeability. We have used specifically designed microbubbles to create a
gene and doxorubicin delivery system.
Previously, we had loaded microbubbles with naked DNA to be delivered to rat hearts.
While this technique does work, despite systemic intravenous injection of loaded
microbubbles, the transgene expression time is too short and efficiency is too low. Therefore,
we developed a new system using adeno associated virus particles that can be transfected into
the heart, using ultrasound targeted microbubble destruction. This allows a more efficient and
very long transgene expression in the myocardium. Using this technique, we were able to
deliver both reporter genes to rat hearts, as well as an oxygen stable HIF1-alpha mutant, that
would induce significant angiogenesis in the heart. This technique is presently transferred to a
large animal model using retroperfusion of virus loaded microbubbles into the coronary veins.
In a different work a novel microbubble carrier for doxorubicin has been developed and
characterized in-vitro. The newly developed doxorubicin-loaded microbubbles possess a soft
but stable phospholipid monolayer shell. Importantly, the active drug is embedded in the
microbubble shell and is complexed to the phospholipids by both electrostatic and hydrophobic
interactions. Despite their drug load, these novel microbubbles retained all important physical
characteristics for ultrasound targeted microbubble destruction, comparable with the
commercially available ultrasound contrast agents. In cell culture studies doxorubicin-loaded
microbubbles in combination with ultrasound demonstrated a 3.2 fold increase of the antiproliferative activity compared to free doxorubicin and doxorubicin-loaded liposomes.
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Ultrasound-Mediated Drug Delivery using Echogenic
Christy K. Holland, Jonathan Kopechek, Kathryn Hitchcock (Biomedical Engineering,
Univ. of Cincinnati, Cincinnati, OH, USA), Danielle Caudell, Gail Pyne-Geithman (Dept. of
Neurology, Univ. of Cincinnati, Cincinnati, OH), Shao-Ling Huang, Ph.D., David D.
McPherson, M.D. (Dept. of Internal Medicine, Univ. of Texas Health Science Center,
Houston, TX, USA)
Due to the prevalence of thrombo-occlusive and atherosclerotic disease worldwide and the need for
improved clinical treatments, pulsed ultrasound in combination with drugs have been investigated to
improve recanalization in patients with these diseases. Acceleration of clot removal is particularly
critical in the treatment of acute ischemic stroke. Echogenic immunoliposomes are under development
to enable ultrasound-controlled drug delivery. Mechanistic studies in vitro have revealed that stable
cavitation is correlated with enhanced penetration of recombinant tissue Plasminogen Activator (rt-PA)
into clot and with enhanced drug delivery across the vascular endothelium. A review of in vitro
sonothrombolysis studies utilizing a commercial ultrasound contrast agent or echogenic liposomes
loaded with rt-PA to nucleate stable cavitation will be presented. Strategies to harness bubble activity
using infusions of echo contrast agents and image-guided, targeted drug delivery schemes will be
reviewed. This work was supported by NIH 2RO1 NS047603, NIH 1RO1 HL074002, and NIH 2R01
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Drug uptake by endothelial cells through targeted
microbubble sonoporation
Klazina Kooiman1, Miranda Foppen-Harteveld1, and Nico de Jong1-2-3
1- Dept. of Biomedical Engineering, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands
2- Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
3- Dept. of Applied Physics, Physics of Fluids, University of Twente, Enschede, the Netherlands
Molecular imaging using ultrasound makes use of targeted ultrasound contrast agents that consist of
encapsulated gas microbubbles. Until now, targeted microbubbles have only been used for imaging, not
drug delivery. Drug uptake using microbubbles can be induced by sonoporation, a method that induces
transient cell membrane pores by oscillating or jetting microbubbles so that therapeutics can enter the
cell. So far, sonoporation has only been induced using non-targeted microbubbles [1,2]. Due to the
blood flow, there may be insufficient microbubble-cell contact in vivo. A microbubble targeted to the
cell membrane may overcome this, but it is not known whether sonoporation can still be induced. This
study focuses on inducing sonoporation with CD31-targeted microbubbles in endothelial cells at low
acoustic pressures. CD31 was chosen since this adhesion molecule is expressed constitutively on the
surface of endothelial cells [3].
Biotinylated lipid coated microbubbles with a C4F10 gas core were made by sonication [4]. After CD31
antibody conjugation [5], microbubbles were added to human umbilical vein endothelial cells grown in
an Opticell. The microbubbles were allowed to adhere to the cells by flotation for 5 min. The Opticell
was then reversed and mounted in the set-up such that the bound microbubbles were on top of the cells.
Microbubble-cell behavior upon insonification at 1 MHz (6x 10 cycle sine-wave bursts) at 80, 120 and
200 kPa peak negative acoustic pressure was studied with the Brandaris 128 high-speed camera [6]
(frame rate ~12 MHz). Microbubble diameter (D) – time curves were extracted from the recordings and
the relative vibration Dmax – Dmin normalized to the resting diameter D0 were determined. The cellimpermeable propidium iodide (PI; 25 μg/ml) was used as indicator for increased cell membrane
permeability due to sonoporation. PI uptake was detected using fluorescence and recorded with a high
sensitivity CCD camera (LCL-902K, Watec, Orangeburg, NY, USA).
A total of 31 cells were studied that all had one microbubble attached per cell. After insonifying the
targeted microbubbles at 80 kPa, PI uptake was observed in six cells (30%). Fourteen cells (70%)
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showed no PI uptake. At 120 kPa, one cell (20%) had taken up PI whereas four cells (80%) showed no
PI uptake. At 200 kPa, five cells (83%) had taken up PI whereas one cell (17%) showed no PI uptake.
Overall, PI uptake was observed in 12 cells (39%). Brandaris 128 high-speed camera recordings
revealed the behavior of the targeted microbubbles upon insonification. The figure shows the relation
between the relative vibration of the adhered microbubbles (Dmax – Dmin)/D0, the resting size of the
microbubbles D0 and the induction of PI uptake. The relation suggests that when a microbubble
adhering to an endothelial cell is larger than 3.0 μm or the relative vibration is greater than 0.5,
sonoporation is most likely induced for insonification at 1 MHz. Interestingly, this is irrespective of the
peak negative acoustic pressure the microbubbles were insonified at. Ultrasound treatment alone did not
induce sonoporation at all three studied peak negative acoustic pressures.
Figure. Relation between relative vibration of microbubbles (Dmax – Dmin)/D0, resting size of microbubbles D0, and induction
of sonoporation. Targeted microbubbles were insonified at 1 MHz (6x 10 cycle sine-wave bursts) at 80 kPa (squares; n=20),
120 kPa (triangles; n=5), and 200 kPa (spheres; n=6) peak negative acoustic pressure. Black symbols: no propidium iodide
uptake by endothelial cell; red symbols: propidium iodide uptake by endothelial cell.
This study reveals that targeted microbubbles can induce sonoporation. This feature may now be used
in molecular imaging using ultrasound, thereby combining imaging and drug delivery.
Acknowledgments: This project is supported by innovation subsidies collaborative projects by the
Dutch Ministry of Economic Affairs under number IS042035. The authors would like to thank A.L.
Klibanov from the University of Virginia, Cardiovascular Division, Charlottesville, Virginia, USA for
discussions about the microbubble preparation.
[1] van Wamel et al, J Control Rel 2006; 112: p. 149
[2] Schneider, J Endourol 2008; 22: p. 795
[3] DeLisser et al, Immunol Today 1994; 15: p. 490
[4] Klibanov et al, Invest Radiol 2004; 39: p. 187
[5] Lindner et al, Circulation 2001; 104, p. 2107
[6] Chin et al, Rev Sci Instru 2003, 74: 5026
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Tumor therapy by microbubbles and ultrasound:
mechanism of tumor growth control
A.L. Klibanov, T.I. Shevchenko, B. Kundu, Z. Du,
M. Bohmer, B.I. Raju, R. Seip, C.T. Chin.
University of Virginia, Charlottesville VA, 22908-0158
Philips Research, Eindhoven NL and Briarcliff Manor NY.
Introduction. Destruction of microbubbles in the vasculature by medical ultrasound is known to induce
non-thermal bioeffects, such as petechial hemorrhaging [1,2], enhancement of nanoparticle
extravasation [3], opening of blood-brain barrier [4], therapeutic angiogenesis [5] and antivascular
action [6]. We have hypothesized that destruction of microbubbles in the tumor vasculature would
cause vascular endothelium destruction and direct contact of pro-thrombotic tissue factor with the
blood, leading to clotting and reduction of tumor blood supply. Contrary to this initial hypothesis, our
microbubble+ultrasound treatment, yet tumor growth could be inhibited and even reversed. This study
was performed in order to investigate the potential mechanisms of the observed tumor therapy effect.
Methods. Decafluorobutane microbubbles stabilized with a monolayer of phosphatidylcholine and PEG
stearate (mean particle size <2.5 um) were prepared in house and stored refrigerated in sealed vials
under decafluorobutane atmosphere. MC38 mouse colon adenocarcinoma cells (courtesy Dr. J. Schlom,
NIH) were subcutaneously grafted in the left hind leg of C57BL/6 female mice. After tumor could be
visually detected and its size measured with a caliper, therapy was initiated.
Animal study was performed in accordance with a UVA ACUC-approved protocol; all animal
experiments were performed under isoflurane gas anesthesia. Microbubble dispersion in normal saline
(50.106 bubbles in 50 ul) was administered intravenously in the tumor-bearing mice. It was
immediately followed by insonation of tumor using TIPS system (Philips Research) operated in the
intermittent mode (1 Hz, 1.2 MHz, 100,000 cycles, 5MPa peak negative acoustic pressure). Imaging
guidance for TIPS treatment was provided by intra-operative high frequency scanhead (HDI 5000 or
iE33 ultrasound imaging systems were used). Imaging transducer was mounted laterally on the side of
TIPS probe water standoff assembly. Microbubble & ultrasound treatment was repeated twice daily, for
a period of two weeks. Tumor size was measured daily with a caliper. As per ACUC protocol, mice
were euthanized if tumor load reached 10% of the animal body mass. The animal body mass and
general mouse appearance and behavior were assessed for signs of side effects. Seven tumor-bearing
animals were used in each of the experimental and control groups.
For evaluation of tissue metabolism, 18F-fluorodeoxyglucose (FDG) administration combined with
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microPET imaging was performed in a separate set of experimental animals, a day before and a day
after microbubble-ultrasound treatment. Frozen section histology was used to evaluate control and
insonated tissues for the presence of leukocytes. Tumor temperature increase during insonation was
evaluated with a needle thermocouple; it was minimal, always under3oC.
Results. Circulating microbubbles could be clearly observed by ultrasound imaging in the tumor
vasculature. Microbubble destruction in response to TIPS treatment was observed; brief (up to several
minutes) reduction of tissue perfusion after TIPS treatment pulses was clearly detected.
Untreated animals, as well as mice from control groups which only received either microbubbles or
ultrasound separately, demonstrated rapid tumor growth, resulting in the necessity to perform
euthanasia. The group of animals receiving the combination microbubble+ultrasound treatment
demonstrated significant inhibition of tumor growth and in some instances a reduction of tumor size; no
euthanasia was required for those animals for the duration of the study.
Tumor-bearing hind leg tissue insonated after microbubble administration demonstrated significant
accumulation of FDG as compared with non-insonated tumors, indicating an increase in metabolic
activities. Such increase of FDG uptake cannot be explained by the increase of tumor cell metabolism,
because tumor growth is inhibited. However, it can be attributed to the leukocyte accumulation in the
insonated tissues. Histology of the muscle tissue insonated after microbubble administration showed
significant accumulation of leukocytes in the tissue 24 hours after treatment; leukocytes may be
responsible for the enhancement of FDG uptake in the insonated tumors.
Conclusion. Destruction of microbubbles in the tumor vasculature results in the reduction of tumor size
and inhibition of tumor growth. Direct tumor cell killing by either mechanical or thermal effects should
not be significant and cannot explain the therapeutic effects; likewise, it is unlikely to be caused by the
brief (minutes) reduction of the tumor blood flow. A more promising hypothesis is the induction of
inflammatory response subsequent to cavitation events in close proximity to vascular endothelium,
leading to the accumulation and activation of leukocytes that may provide antitumor effect.
Acknowledgment. This study was supported by NIH R21/33 CA102880 to A.L. Klibanov.
1. Skyba DM, Price RJ, Linka AZ, Skalak TC, Kaul S. Direct in vivo visualization of intravascular destruction of
microbubbles by ultrasound and its local effects on tissue. Circulation. 1998;98:290-293.
2. Wible JH Jr, Galen KP, Wojdyla JK, Hughes MS, Klibanov AL, Brandenburger GH. Microbubbles induce
renal hemorrhage when exposed to diagnostic ultrasound in anesthetized rats. Ultrasound Med Biol.
3. Price RJ, Skyba 39DM, Kaul S, Skalak TC. Delivery of colloidal particles and red blood cells to tissue through
microvessel ruptures created by targeted microbubble destruction with ultrasound. Circulation. 1998;98:12641267.
4. Hynynen K, McDannold N, Vykhodtseva N, Jolesz FA. Non-invasive opening of BBB by focused ultrasound.
Acta Neurochir Suppl. 2003;86:555-558.
5. Chappell JC, Song J, Klibanov AL, Price RJ. Ultrasonic microbubble destruction stimulates therapeutic
arteriogenesis via the CD18-dependent recruitment of bone marrow-derived cells. Arterioscler Thromb Vasc Biol.
6. Bunte RM, Ansaloni S, Sehgal CM, Lee WM, Wood AK. Histopathological observations of the antivascular
effects of physiotherapy ultrasound on a murine neoplasm.Ultrasound Med Biol. 2006;32:453-461.
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Review of vascular imaging with Contrast-enhanced
ultrasound (CEUS)
Steve Feinstein, MD, FACC
Professor of Medicine,Rush University Medical Center,Chicago, Illinois USA
Proliferation of the arterial adventitial vasa vasorum presages the early atherosclerotic development
and plaque vulnerability. Recent advances using CEUS provides direct visualization of the vasa
vasorum and intra-plaque neovascularization. This CEUS methodology serves as a new surrogate
marker for the detection and monitoring of premature and advanced atherosclerosis. This presentation
will review the clinical value of CEUS for identifying and quantifying carotid artery vasa vasorum and
intra-plaque neovascularization. The presentation will provide a road map for developing and validating
the CEUS techniques ranging from in vitro calibration to 3D representation and quantification. Once
clinically validated, the uses of CEUS may provide a method to non-invasively monitor therapeutic
interventions. And importantly, the therapeutic ultrasound will be discussed focused on the use of
ultrasound-directed, site-specific therapy for drug and gene delivery systems. These combined
applications for diagnosis and therapy provide unique opportunities for clinicians to image and direct
therapy for individuals with vulnerable lesions.
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Plaque Imaging
Professor Edward Leen, Dr David Owen, Dr Jo Shalloup & Professor Alun Davies
Imperial College London, Hammersmith and Charing Cross Campus, London
Traditionally, stroke risk stratification has been based on the degree of internal carotid artery
luminal narrowing, and the presence of recent focal neurological symptoms related to the ipsilateral
cerebral hemisphere. Results of the European Carotid Surgery Trial (ECST) and the North American
Symptomatic Carotid Endarterectomy Trial (NASCET) highlights the importance of accurate
assessment of the degree of internal carotid artery stenosis. Extensive work had been undertaken in the
generation of reliable and reproducible criteria for the calculation of internal carotid artery stenosis
using conventional duplex ultrasonography measuring peak velocities. Duplex ultrasonography remains
the first line imaging modality in this context.
However, it is now evident that the degree of stenosis alone is a relatively poor predictor of
future stroke in asymptomatic patients. Indeed, the Asymptomatic Carotid Surgery Trial (ACST)
highlighted the need to identify the subgroup of asymptomatics that would benefit from intervention. In
order to define this subgroup, research has been focused on the evaluation of the morphology of plaques
in vivo using imaging modalities. Histological and functional techniques have determined the features
neovascularisation; intra-plaque haemorrhage; and apoptosis. Imaging intra-plaque inflammation,
neovascularisation, haemorrhage and apoptosis have been attempted with some success using MRI
and/or PET scanning. However, the high prevalence of carotid disease and expense associated with
these imaging techniques preclude them from replacing ultrasound as first line investigation.
Conventional ultrasound has been used to identify plaque constituents with “Gray-Scale
Median” (GSM) evaluation. Studies have consistently demonstrated that plaques, which are echo-lucent
on ultrasound, with a low GSM, have high lipid, haemorrhage and macrophage on histology.
Conversely, echogenic plaques, with a high GSM, have a higher fibrous content. GSM is also
associated with clinical findings: evidence of cerebral infarction on CT is more common in the
presence of echo-lucent plaques rather than echogenic ones, regardless of symptomatic status.
Echogenicity on ultrasound has also been shown to predict ipsilateral ischaemic stroke; patients with
echo-lucent plaques are at increased risk compared with those with echogenic plaques. However,
hazard ratios for development of stroke that are associated with differing echogenicity scores are not
sufficiently great enough to warrant translation into clinical practice. Furthermore, studies investigating
the use of GSM in selection for carotid artery stenting (CAS) have had conflicting results.
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However ultrasound imaging intraplaque neovascularisation may be a means to identify the
high-risk plaque. It is now known that plaques bearing the hallmarks of vulnerability, including
inflammation, haemorrhage, lipid accumulation and thin fibrous caps, are also associated with
increasing neovascularisation. Neovascularisation appears to be an early feature of atherosclerosis,
predating macrophage infiltration, and as the plaque progresses so too does intimal neovascularisation.
Carotid plaques retrieved at endarterectomy have many more microvessels and transcripts known to
promote neovascularisation when they originate from symptomatic, compared with asymptomatic
patients. Furthermore, symptomatic plaques have been shown to contain abnormal, immature vessels
that may precipitate plaque instability through their acting as sites of vascular leakage and
Contrast enhanced ultrasound imaging of the plaque neo-vascularisation has been shown to
correlate with histological findings. Feinstein and colleagues reported a moderate correlation value of
0.64; Coli et al reported an increase in neovascularisation in patients demonstrating extensive
enhancement; Giannoni et al reported diffuse contrast uptake in plaques from symptomatic patients, all
of whom had increased number of microvessels confirmed on histology. The latter group described the
common presence of small vessels within plaque underlying ulcerations. Up until that point, these three
groups used subjective visual assessment made by human readers to ascribe binary or discreet scores to
the imaging findings. Using a quantitative method, Xiong and colleagues who studied 104 carotid
stenoses, revealed that plaque enhanced intensity and the intensity normalised against carotid luminal
intensity were both significantly greater in symptomatic versus asymptomatic atheromata. Current
CEUS methodologies for plaque imaging will be addressed as well as novel methods of identifying
plaque vulnerability will be discussed in this presentation.
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Late Phase Contrast Enhanced Ultrasound to Assess
Inflammation within Carotid Atherosclerotic Plaque
David R.J. Owen
The carotid atherosclerotic plaques most vulnerable to rupture are those with a large
inflammatory infiltrate (1-5). Hence there has been considerable interest in imaging inflammation
within atherosclerotic plaques with PET and MRI, but given the prevalence of atherosclerosis, costs
grounds alone prohibit these techniques from being translated into routine clinical practice.
Late phase contrast enhanced ultrasound (LP-CEUS) may represent a low cost means of
detecting plaque inflammation. Ultrasound contrast agents (microbubbles) are phagocytosed by
monocytes in vitro and remain acoustically active for up to 30 minutes (6;7). Furthermore, preclinical
studies show that microbubbles can be detected within monocytes which are attached to the
endothelium of inflamed tissue (8). It has also been demonstrated that microbubbles adhere directly to
the surface of damaged endothelium (9).
The purpose of this study was to determine whether non-targeted microbubbles are retained in
human carotid plaque in sufficient number to be detected by late phase contrast enhanced ultrasound.
This prospective study was approved by the local Research Ethics Committee. Informed
consent was obtained from all subjects prior to their examination. Between December 2008 and May
2009 we recruited subjects aged 18 years or over who presented to the vascular clinic for a carotid
duplex ultrasound scan at our institution, and whose scan showed an atherosclerotic plaque of > 30%
stenosis by velocity criteria.
Plaques were defined as symptomatic if symptoms consistent with stroke, transient ischaemic
attack (TIA) or amaurosis fugax had occurred within 12 months of entry into the study, in the
neurovascular territory of the plaque studied. Plaques were defined as asymptomatic if no such events
had ever occurred within their neurovascular territory. There was no significant difference between the
symptomatic and asymptomatic groups in age, gender, or history of diabetes mellitus, hypertension,
presence of an HMG-CoA reductase inhibitor (statin) on their prescription, and smoking.
The examination was performed with the subject in the supine position using a Philips (Bothel,
WA) iU22 ultrasound scanner equipped with a high frequency linear array L12-5 MHz probe. The
contrast agent used was SonoVue™ (Bracco spa, Milan, Italy). 2mL of this preparation was injected as
an intravenous bolus into an antecubital vein. CEUS was performed with flash-imaging at intermediate
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mechanical index of the carotid bifurcation and internal carotid artery, using a non-linear imaging
(power modulation) contrast mode, 6 minutes following the bolus contrast injection. Six flash frames
were acquired in less than 1 second in the axial orientation at the level of greatest stenosis. The cineloop of the acquisition was saved on the hard-drive and QLAB software (Philips; Bothel, WA) was
used to quantify echo intensity of the plaque using raw linear data. All regions of interest (ROIs) were
drawn by an ultrasonologist with 17 years experience (EL) who was blinded to the medical history.
Using the fundamental B mode image, a single ROI was drawn on the outline of the plaque. The ROI is
automatically mapped to the same position on the contrast image, and QLAB calculates the signal
intensity of each pixel within the ROI. The mean signal intensity is then automatically calculated. A
second ROI was drawn around the residual lumen to calculate mean signal intensity in the lumen.
The data was log transformed for statistical analysis. The signal intensity of the plaque was
normalised by dividing the plaque signal intensity by the lumen signal intensity (because the data was
log transformed, normalisation required subtracting the lumen signal intensity from the plaque signal
intensity). The normalised signal was compared between the two groups (symptomatic and
asymptomatic) using the t-test, assuming unequal variances.
The LP-CEUS normalised plaque intensity was significantly greater in the symptomatic group
0.3899 (95% CI: -0.1056 to 0.8854) than the asymptomatic group -0.6869 (95% CI: -1.036 to -0.3380),
(P=0.0005). Of note, the lowest signal intensity from the symptomatic group was derived from the
subject who had the longest event to scan time (of nearly 1 year). For this subject, the signal fell below
the mean of the asymptomatic group.
There was no correlation between normalised LP-CEUS plaque intensity and percentage
luminal stenosis (P=0.27).
There was no evidence of a relationship between diabetes, smoking history, or statin dose with
LP-CEUS signal, nor of differential LP-CEUS signal between those subjects in the symptomatic group
with TIA versus CVA.
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Figure 1
Normalised Plaque LP-CEUS signal Intensity
Symptomatic Subjects
Asymptomatic Subjects
The figure shows mean and standard error of mean
Our study has demonstrated that the LP-CEUS signal intensity of carotid plaques is greater from
plaques which are symptomatic (ie within the neurovascular territory of a recent cerebrovascular event),
compared those which are asymptomatic. This suggests that plaques responsible for cerebrovascular
events are those that tend to have late sonographic enhancement. This finding may merely represent the
fact that symptomatic plaques have more intraplaque blood volume than asymptomatic plaques, and
thus contain more circulating microbubbles in the late phase, just as they do with dynamic contrast
enhanced ultrasound (10). But this is unlikely because, during the dynamic phase, the signal from the
lumen is approximately two orders of magnitude greater than the signal from the plaque. Were the late
phase plaque signal purely a result of circulating microbubbles, it should only represent a small fraction
of the late phase lumen signal. The fact that the late phase signals of plaque and lumen are of similar
magnitude, implies that microbubbles have accumulated within the plaque. Biological plausibility of
this theory is provided by preclinical work demonstrating that microbubbles are passively targeted to
tissue with activated endothelium and/or inflammation (6;8;9). We therefore suggest that by detecting
retained untargeted microbubbles, LP-CEUS has the potential to detect inflammation and/or endothelial
activation within carotid plaque in vivo.
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By quantifying intraplaque inflammation, LP-CEUS is able to distinguish groups of symptomatic from
asymptomatic patients. LP-CEUS may therefore represent a tissue specific marker of inflammation.
Reference List
(1) Virmani R, Burke AP, Farb A, Kolodgie FD. Pathology of the vulnerable plaque. J Am Coll Cardiol
2006 Apr 18;47(8 Suppl):C13-C18.
(2) Schaar JA, Muller JE, Falk E, Virmani R, Fuster V, Serruys PW, et al. Terminology for high-risk and
vulnerable coronary artery plaques. Report of a meeting on the vulnerable plaque, June 17 and 18, 2003,
Santorini, Greece. Eur Heart J 2004 Jun;25(12):1077-82.
(3) van der Wal AC, Becker AE, van der Loos CM, Das PK. Site of intimal rupture or erosion of thrombosed
coronary atherosclerotic plaques is characterized by an inflammatory process irrespective of the
dominant plaque morphology. Circulation 1994 Jan;89(1):36-44.
(4) Boyle JJ. Association of coronary plaque rupture and atherosclerotic inflammation. J Pathol 1997
(5) Moreno PR, Falk E, Palacios IF, Newell JB, Fuster V, Fallon JT. Macrophage infiltration in acute
coronary syndromes. Implications for plaque rupture. Circulation 1994 Aug;90(2):775-8.
(6) Lindner JR, Dayton PA, Coggins MP, Ley K, Song J, Ferrara K, et al. Noninvasive imaging of
inflammation by ultrasound detection of phagocytosed microbubbles. Circulation 2000 Aug
(7) Yanagisawa K, Moriyasu F, Miyahara T, Yuki M, Iijima H. Phagocytosis of ultrasound contrast agent
microbubbles by Kupffer cells. Ultrasound Med Biol 2007 Feb;33(2):318-25.
(8) Lindner JR, Coggins MP, Kaul S, Klibanov AL, Brandenburger GH, Ley K. Microbubble persistence in
the microcirculation during ischemia/reperfusion and inflammation is caused by integrin- and
complement-mediated adherence to activated leukocytes. Circulation 2000 Feb 15;101(6):668-75.
(9) Tsutsui JM, Xie F, Cano M, Chomas J, Phillips P, Radio SJ, et al. Detection of retained microbubbles in
carotid arteries with real-time low mechanical index imaging in the setting of endothelial dysfunction. J
Am Coll Cardiol 2004 Sep 1;44(5):1036-46.
(10) Xiong L, Deng YB, Zhu Y, Liu YN, Bi XJ. Correlation of carotid plaque neovascularization detected by
using contrast-enhanced US with clinical symptoms. Radiology 2009 May;251(2):583-9.
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In vivo targeting of mouse carotid artery endothelium using
echogenic perfluorohexane loaded macrophages
Kornmann LK, Zernecke A, Curfs DM, van der Made I, Janssen BJ, De Winther MP,
Reneman RS, Hoeks AP, Reesink KD
Molecular imaging of the microcirculation using ultrasound contrast agents is shown to be successful.
Targeting the endothelium of large arteries, however, is difficult due to demanding adherence
requirements as a result of a high wall shear stress.
To investigate the potential of monocytes to act as ultrasound contrast agent, providing selective
adhesion to activated murine carotid artery endothelium and echo signal enhancement.
Murine bone marrow derived macrophages (BMM) were incubated for 3h with different concentrations
of perfluorohexane (PFH) emulsions (Fig. A). Effects of PFH loading on BMM adhesion molecule
expression (i.e., PSGL-1, VLA-4, Mac-1, LFA-1) were analyzed by flow cytometry. Static (no flow)
adhesion of PFH loaded BMM to TNF-α stimulated b.End5 endothelial cells was assessed in vitro by
microscopy. Echogenic potential was evaluated in an experimental setup (agar wells) using a medical
ultrasound scanner. The size distribution of loaded and unloaded BMM was compared to native murine
blood leukocytes by microscopy (N=200 per group). In vivo, echogenicity of the BMM in blood was
evaluated with an ultrasound scanner for small animals. The interaction of the BMM with TNF-α
stimulated endothelium in the carotid artery was assessed by intravital microscopy.
In vitro, incubation of BMM with PFH emulsions resulted in dose-dependent uptake and echogenicity
(5-17 dB). Flow cytometry showed no down-regulation of BMM adhesion molecule expression due to
PFH loading. Static adhesion to b.End5 endothelial cells was preserved, although PFH loading tended
to attenuate the number of adherent cells. Both loaded and unloaded BMM (medians 17.3 and 16.6 μm,
no difference in size, p=0.051) were significantly larger than blood monocytes (14.0 mm), but
distributions were overlapping in the 12-16 mm range. After intravenous injection, PFH loaded BMM
did enhance blood echogenicity in vivo, but unloaded BMM did not (Fig. B). Moreover, the injected
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macrophages exhibited rolling and adhesion behaviour on the TNF-α stimulated carotid artery
endothelium, similar to native blood leukocytes (Fig. C). Rolling behaviour was not different (p=0.33)
between PFH loaded and unloaded BMM (Fig. D). Similarly, there was no difference in the number of
adherent loaded and unloaded BMM (p=0.25).
Our findings demonstrate that, in vivo, perfluorohexane loaded macrophages enhance the echogenicity
of circulating blood. Moreover, the loaded macrophages roll and adhere selectively to carotid artery
endothelium under physiological flow conditions, which substantiates their potential to act as contrast
Figure: see below
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Imaging Angiogenesis with Cyclic Peptide Microbubbles
C. Anderson, X. Hu, J. Tlaxca, A.L. Klibanov, M. Lawrence, K. Ferrara, J. Rychak
Ultrasound molecular imaging of angiogenesis has strong potential for both clinical use and as a
research tool in tumor biology and development of anti-angiogenic therapies. In the current study, we
describe the development and characterization of microbubbles bearing cyclic peptides. Such small
peptides offer the advantages of low cost and ease of synthesis relative to conventional protein ligands,
although the target specificity of small ligands can be sub-optimal. Two ligands were examined: 1) a
cyclic RGD peptide, which is known to bind alpha-v beta-3 and other integrins that are up-regulated on
angiogenic endothelium, and 2) a control cyclic RAD peptide which was not expected to exhibit any
integrin adhesion. Peptides were bound to the microbubble surface using covalent conjugation
chemistries, and conjugation efficiency was assessed fluorometrically. We measured the adhesion of
targeted microbubbles under laminar flow conditions on a surface of recombinant murine alpha-v beta3 integrin. Significant adhesion of cRGD, but not cRAD, microbubbles was observed; binding was
reduced by >90% upon blocking with an anti-alpha- v beta-3 integrin antibody. We next assessed
microbubble adhesion on confluent murine endothelial cells that express alpha-v beta-3, and observed
approximately 10-times greater adhesion of cRGD compared to cRAD or naked microbubbles.
However, pre-incubating the endothelial cells with blocking antibodies against the alpha-v, beta-3, or
both subunits of the integrin resulted in 80%, 44%, and 75% reduction in cRGD microbubble adhesion,
respectively. This data suggests that although the cRGD peptide is able to bind alpha-v beta-3 integrin
with affinity sufficient to mediate microbubble adhesion, endothelial cells may express other targets
that may account for up to ~20% of the observed microbubble retention. We assessed cRGD and cRAD
microbubble adhesion in two mouse models of tumor angiogenesis: a syngeneic model of
gastrointestinal cancer and a human xenograft model of breast cancer. We observed approximately 1520 times greater signal from cRGD microbubbles relative to non-targeted control microbubbles in both
models. Interestingly, we observed a significant signal from cRAD microbubbles in both models,
although at different magnitudes. Our results suggest that microbubbles targeted with a cyclic RGDcontaining peptide are able to bind to alpha-v beta-3 integrins, although other targets are expressed in
vitro and likely in vivo. The correlation between these unknown targets and angiogenesis is not yet
known. Additionally, cRGD microbubbles exhibit significant accumulation and contrast enhancement
in mouse models of tumor growth.
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The 15th European Symposium on Ultrasound Contrast Imaging
Rotterdam is sponsored by:
GE Healthcare
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Senior Brand Manager
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Medical Diagnostics
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